Failed Antegrade Recanalization Research Articles

Role of Retrograde Tibiopedal Access in Limb Salvage in Patients with Critical Lower Limb Ischemia

AbstractThe aim of this study was to assess the efficacy and safety of retrograde tibiopedal access as an alternative approach in cases of critical limb ischemia (CLI) when antegrade access has failed. A prospective study was conducted that included patients with CLI who underwent tibiopedal access after failed antegrade recanalization from January 2018 to June 2022. Follow-up was conducted at 6, 12, and 24 months. The primary outcomes evaluated were technical success rate and primary patency. Secondary outcomes included complication rate, mortality rate, and limb salvage rate (LSR). Forty-eight patients had CLI and Trans Atlantic Inter-Society Consensus infrainguinal lesions. The retrograde approach was used through the anterior tibial artery in 28 patients (58%), the posterior tibial artery in 18 patients (37.5%), and the peroneal artery in 2 patients (4.5%). Technical success was achieved in 90% of patients (43 patients). There was a significant increase in the anklebrachial index after the procedure with a mean follow-up of 22 months. Twenty-two months primary patency rate was 85.2%, while secondary patency rate was 100% and LSR was 96%, respectively. There was no mortality in the series. Retrograde tibiopedal approach is an alternative option for managing peripheral arterial disease and CLI. This method offers another means of crossing lesions when antegrade access failed, and the intervention can be completed either in an antegrade or retrograde approach. As the retrograde approach does not impact access site, considered a feasible safe treatment alternative which increase the success rate of endovascular treatment.

Retrograde popliteal and pedal access in management of superficial femoral artery occlusion after failed antegrade approach: a comparative study

Aim To evaluate feasibility, efficacy, and safety of popliteal access compared to tibial retrograde approach for management of chronic total occlusion of superficial femoral artery after failed antegrade recanalization. Patients and methods The study was carried out from January 2016 to April 2019 at Sohag University Hospitals on 30 patients experiencing chronic total occlusion of superficial femoral artery and underwent retrograde transpopliteal or transpedal approach after failed antegrade intervention. Technical success and procedure-related complications were evaluated and compared among patient groups. Results Popliteal access was performed in 14 patients, whereas pedal puncture was accessed in 16 patients. Mean age was 57 (50–64) and 63 (52–65) years in popliteal and pedal access groups, respectively. There were no significant differences in patient baseline characteristics. Arterial puncture was successful in pedal than popliteal access (94.4 vs. 92.9%, P=0.96). Technical success was higher in patients with pedal access than those with popliteal puncture (87.5 vs. 78.6%, P=0.19). Operative time was shorter in pedal access than popliteal access (90±35, 120±28 min, P=0.04). Time to achieve hemostasis was 12±4.6 and 5±1.7 min in popliteal and pedal access, respectively (P=0.022). Access-site hematoma was higher in popliteal access group than pedal access group (28.6 vs. 6.3%, respectively, P=0.042). Spasm of pedal vessels occurred in three (18.8%) patients, acute thrombosis in two (6.7%) patients, access-site occlusion in one (6.3%) patient, and wire perforation in two (12.5%) patients. Conclusion When antegrade revascularization fails, retrograde access offers another endovascular option to treat critical limb ischemia before going to open vascular surgery, especially in high surgical risk patients. When both popliteal and pedal approaches are available, pedal access procedure is more preferable as it is relatively easier with less puncture-site complication.

An Alternative Treatment of Stump Occlusion of the Superficial Femoral Artery with Percutaneous Direct Puncture Followed by Antegrade Recanalization

IntroductionThe purpose of the study was to evaluate the efficacy and safety of the “percutaneous direct puncture of occluded superficial femoral artery (SFA)” technique for recanalization of SFA, after failure of antegrade recanalization in patients with limited access to retrograde popliteal and crural arteries. Material and methodsBetween April 2014 and November 2017, 10 patients with CLI (Critical limb ischemia) underwent endovascular recanalization with direct percutaneous puncture of occluded SFA after failed antegrade recanalization. All patients had a long segment (39,9 ± 2.8 cm) occluded SFA without stump causing failed antegrade recanalization with a cannulated guidewire in the SFA origin. After unsuccessful attempts with the antegrade approach, the retrograde direct puncture technique of the occluded SFA was performed and followed by antegrade recanalization. Patients were followed up clinically with Doppler ultrasonography and according to the Rutherford scale at 1, 3, 6 and 12 months after discharge. ResultsTechnical success was achieved in 8/10 patients (80%).The mean follow-up period was 25,1 ± 9,6 months. One patient underwent major amputation, resulting in 90% limb salvage rate at 12 and 24 months. Amputation-free survival estimated by Kaplan-Meier analysis was 60% at 12 and 24 months. Primary patency rates were 62.5% at 12 and 24 months and secondary patency rates were 87.5% at 12 and 24 months. ConclusionTreatment of SFA occlusions without a stump in CLI patients via the percutaneous direct puncture of occluded SFA approach improved technical success and clinical recovery, especially in cases unsuitable for conventional antegrade and retrograde approaches.

Short term outcome of retrograde tibiopedal access in management popliteal and infrapopliteal disease

Background: Aim was to evaluate the safety and efficacy of retrograde tibiopedal access after failed antegrade recanalization in patients with femero-popliteal and infrapopliteal occlusions.Methods: This is a retrospective study including patients presenting with critical limb ischemia due to femero-popliteal and infrapopliteal occlusions for whom retrograde transpedal/tibial access was used after failure of antegrade approach at the vascular surgery unit in Kasr Al Aini hospitals in the period from June 2015 to June 2017.Results: The study included 18 patients with a mean age of 64 years and male to female ratio 2.6:1. All patients presented with CLI (Rutherford category 4-6), all lesions were Trans Atlantic Society Consensus (TASC) II D, and Technical success was accomplished in 17 cases (94.4 %). In one case, failure to cross the target lesion via both antegrade and retrograde accesses occurred and the patient was immediately converted to an open surgery (popliteal tibial bypass). Complications included 2 puncture site hematoma that were managed conservatively; no AVF. There was no perioperative mortality. Primary patency was 81.25 % at 6 month.Conclusions: retrograde tibiopedal access is safe and effective technique after failed antegrade recanalization in patients with popliteal and infrapopliteal occlusions.

Outcomes of infrageniculate retrograde versus transfemoral access for endovascular intervention for chronic lower extremity ischemia

ObjectiveRetrograde infrageniculate access is an alternative treatment strategy for patients who have failed to respond to antegrade endovascular intervention. This study compares the outcomes of infrageniculate retrograde arterial access with the conventional transfemoral access for the endovascular management of chronic lower extremity ischemia. MethodsThis was a retrospective single-center review of retrograde endovascular intervention (REI) from 2012 to 2016. Indications for intervention, comorbidities, complications, procedural success, limb outcomes, and mortality were analyzed. Technical failure was defined as the inability to complete the procedure because of failed access or unsuccessful recanalization. Infrageniculate access and transfemoral access were obtained with ultrasound or angiographic roadmap guidance. Patency rates were calculated for technically successful interventions. ResultsThere were 47 patients (85% presenting with critical limb ischemia) who underwent sheathless REI after failed antegrade recanalization of TransAtlantic Inter-Society Consensus class D infrainguinal lesions, whereas 93 patients (83% with critical limb ischemia) underwent standard transfemoral access. There were 16 (34%) femoropopliteal, 14 (30%) tibial, and 17 (36%) multilevel interventions in the retrograde group compared with 41 (41%) femoropopliteal, 20 (20%) tibial, and 39 (39%) multilevel interventions in the transfemoral group. Access sites for the retrograde group included the dorsalis pedis (26%), midcalf peroneal (24%), anterior tibial (22%), posterior tibial (26%), and popliteal (2%) arteries. Overall technical success was achieved in 57% of the retrograde group compared with 78% of the transfemoral group. Mean follow-up was 20 months (range, 1-45 months). There were no significant differences in the primary patency rates between the two groups at 1 year and 2 years. The primary assisted patency rates were significantly better in the transfemoral group at 1 year (66% vs 46%; P = .031) and 2 years (56% vs 29%; P = .031). The secondary patency rates were higher in the transfemoral group at 1 year (93% vs 83%; P = .079) and 2 years (91% vs 76%; P = .079), although this did not reach statistical significance. The rate of reintervention was 41% for the retrograde group vs 40% for the transfemoral group. Most of the reinterventions (70% in the retrograde group and 61% in the transfemoral group) were endovascular interventions for a restenosis or occlusion. ConclusionsInfrageniculate access for REI can result in primary patency rates similar to those of antegrade interventions and does not compromise the access site. Technical failure is high in this initial experience and is mostly due to failed recanalization. Limb salvage may be achieved after technical failure with either repeated antegrade intervention or surgical bypass.

Retrograde Transpopliteal Access Is Safe and Effective—It Should Be Added to the Vascular Surgeon's Portfolio

The aim of the study was to review the outcomes of superficial femoral artery (SFA) interventions using a retrograde transpopliteal access approach after failed antegrade recanalization. A database of patients undergoing endovascular treatment of the SFA between 2008 and 2011 was retrospectively queried, and those cases with transpopliteal artery retrograde access were analyzed. Time-dependent outcomes were determined by Kaplan-Meier survival analyses. A total of 16 patients (75% men; mean age 61 ± 9 years) underwent retrograde popliteal access after failed antegrade attempts. Patients had multiple cardiovascular comorbidities with a mean modified cardiac index score of 3.1 ± 1.8. The reason for intervention was lifestyle-limiting claudication in 67% of cases and critical ischemia in the remainder. Most of the lesions were Trans-Atlantic Inter-Society Consensus II C and D. Retrograde ultrasound-guided puncture of the popliteal artery was successful in all cases and there were no local site complications. Intervention was successful in 94% of cases. One uncomplicated perforation (7%) was encountered during attempted recanalization of the SFA in the thigh. There was no perioperative morbidity or 30-day mortality. The 30-day major adverse cardiovascular events rate was 6% but both 30-day major adverse limb events and the 30-day major amputation rate were 0%. There was a 40% increase in actual ankle-brachial index (ABI); 93% of patients achieved an ABI rise >0.15. On longer term follow-up, 2 patients developed restenosis and 1 an asymptomatic occlusion. Both restenosis patients required re-angioplasty. Two patients required expected toe amputations as a result of their presenting symptoms. The primary patency was 66 ± 9%, assisted patency 81 ± 9%, and secondary patency 87 ± 8% at 2 years. Limb salvage was 100%. Clinical efficacy was 63 ± 9% at 2 years. Ultrasound-guided retrograde transpopliteal access is a safe and successful technique, which extends the ability to perform endovascular interventions after failed antegrade approaches.

Combined Antegrade Femoral Artery and Retrograde Popliteal Artery Recanalization for Chronic Occlusions of the Superficial Femoral Artery

PurposeTo evaluate the efficacy and safety of a dual femoral–popliteal approach in the supine position after failed antegrade recanalization attempts in chronic total occlusion (CTO) of the superficial femoral artery (SFA). Materials and MethodsFrom May 2011 to October 2012, 21 patients underwent dual femoral–popliteal recanalization for CTO of the SFA, with a mean lesion length of 87.4 mm ± 5.8. When contralateral antegrade recanalization of SFA occlusions via the common femoral artery could not be achieved, the occlusions were intrainterventionally accessed by retrograde approach via the popliteal artery, which was punctured anteriorly with gently flexed knee and crus extorsion. When the SFA had been recanalized, further angioplasty and stent placement procedures were completed via the femoral artery. ResultsA technical success rate of 100% (entailing puncture of the popliteal artery and SFA recanalization) was achieved, and no hemorrhage, hematoma, pseudoaneurysm, arteriovenous fistula, or other complications developed. During a mean follow-up of 9.8 months ± 1.5, claudication severity, rest pain, and toe ulcers improved significantly. The pulse of the distal arteries, as well as the filling of the veins, could be distinctly felt. Ankle-brachial index changed from 0.48 ± 0.17 to 0.84 ± 0.11 at 1 year after intervention (P < .001), and patency rates at 1, 6, and 12 months after interventions were 100%, 80%, and 42%, respectively. ConclusionsA dual femoral–popliteal approach in the supine position is an alternative backup option after failed attempts at the antegrade approach for patients with proximal barriers in CTO or lesions with major extending collateral vessels.

The clinical utility of below‐the‐ankle angioplasty using “transmetatarsal artery access” in complex cases of CLI

To appraise clinical results of foot arteries recanalization using percutaneous retrograde transmetatarsal arteries access followed by retrograde recanalization of foot and tibial vessels. Arterial revascularization by means of percutaneous transluminal angioplasty (PTA) is a mainstay in the management of patients with critical limb ischemia (CLI). Nonetheless, when employing standard approaches, success rate remain suboptimal. We report the clinical results of foot arteries recanalization through transmetatarsal artery access. From September 2011 to November 2012, 38 patients (28 men; mean age 73.2 ± 11.4 years) underwent transmetatarsal artery access after antegrade recanalization failure, followed by retrograde recanalization of the foot and tibial vessels. The primary end point was TcPO₂ improvement. The secondary end point was limb salvage rate, amputation-free survival rate and radiation exposure. Technical success (ability to deliver the balloon across the lesion and inflate it at nominal pressure) was achieved in 33 (86.84%) of cases, with <50% residual stenosis and no complications. Failures were because of spasm or no true lumen re-entry. During follow-up (mean 6.7 ± 2.3 months/range 1-14) clinical improvement was observed in the patients having technical success, with TcPO₂ increasing, from 10.3 ± 7.6 to 50.7 ± 8.2 mm Hg, avoiding major amputations. Amputation-free survival rate calculated by Kaplan-Meier analysis was 81.5% at 12 months. Radiation exposition was major than in patients treated by antegrade way (45.5 ± 56.1 vs. 52.5 ± 11.5 min of fluoroscopy and 69.1 ± 83.2 vs. 94 ± 26.5 Gym(2) of X-ray dose; P < 0.001). Transmetatarsal artery access appears feasible and beneficial in cases with a failed antegrade recanalization and unsuitable for retrograde pedal/plantar access.

Retrograde Coronary Chronic Total Occlusion Revascularization: Procedural and In-Hospital Outcomes From a Multicenter Registry in the United States

This study sought to examine the contemporary outcomes of retrograde chronic total occlusion (CTO) interventions among 3 experienced U.S. centers. The retrograde approach, pioneered and developed in Japan, has revolutionized the treatment of coronary CTO, yet limited information exists on procedural efficacy, safety, and reproducibility of outcomes in other settings. Between 2006 and 2011, 462 consecutive retrograde CTO interventions were performed at 3 U.S. institutions. Patient characteristics, procedural outcomes, and in-hospital clinical events were ascertained. Mean patient age was 65 ± 9.7 years, 84% were men, and 50% had prior coronary artery bypass surgery. The CTO target vessel was the right coronary artery (66%), circumflex (18%), left anterior descending artery (15.5%), and left main artery or bypass graft (0.5%). The retrograde approach was used as the primary method in 46% of cases and after failed antegrade recanalization in 54%. Retrograde collateral vessels were septal (68%), epicardial (24%), and bypass grafts (8%). Technical and procedural success was 81.4% (n = 376) and 79.4% (n = 367), respectively. The mean contrast volume and fluoroscopy time were 345 ± 177 ml and 61 ± 40 min, respectively. A major complication occurred in 12 patients (2.6%). In multivariable analysis, years since initiation of retrograde CTO percutaneous coronary intervention (PCI) at each center, female sex, and ejection fraction ≥40% were associated with higher technical success. Among selected U.S. programs, retrograde CTO PCI is often performed in patients with prior coronary bypass graft surgery and is associated with favorably high success and low complication rates.

Retrograde Recanalization Technique for Use After Failed Antegrade Angioplasty in Chronic Femoral Artery Occlusions

To describe a technique to approach chronic total occlusions (CTOs) of the superficial femoral artery (SFA) after failed antegrade recanalization as an alternative to a conventional transpopliteal approach. A retrospective analysis was undertaken of 50 patients (37 men; mean age 71 years) who underwent retrograde recanalization via a distal SFA access after failed antegrade recanalization of SFA CTOs that were not beyond the adductor canal. Antegrade recanalization failed due to flush SFA occlusion, occluded stents, wire perforation, and re-entry failure. Retrograde SFA access required introduction of a 7- to 15-cm, 21-G needle distal to the occlusion. A 0.018-inch guidewire was inserted through the needle followed by a 4- or 6-F, 10-cm sheath or dedicated support catheter only. All retrograde SFA punctures were performed with the patient in the supine position. Once retrograde passage of the occlusion was successful, oftentimes requiring a "double-balloon" technique to disrupt the dissection membrane with abutting balloons delivered from both access sites, balloon angioplasty and/or stenting could be performed from either direction. Retrograde puncture of the distal SFA was successful in all cases. Retrograde recanalization involved insertion of a 6-F sheath in 3 (6%) cases, a 4-F sheath in 32 (64%), and a sheathless approach in 15 (30%). The "double-balloon" technique was necessary to achieve guidewire passage in 12 cases. Recanalization was successful in 48 (96%) cases. Hemostasis time at the distal puncture site was 9.2 minutes (range 3-30). Perioperative complications included 4 pseudoaneurysms (2 groins, 2 distal), 1 peripheral embolization, and 1 small arteriovenous fistula at the distal puncture site. For failure of antegrade recanalization of SFA occlusions, the retrograde SFA puncture distal to the adductor canal with the patient remaining supine is a safe and successful technique that represents a convenient alternative to the conventional transpopliteal approach.