Retrograde Approach Research Articles

The evaluation of technical outcome and wire manipulation time within 30min in patients with poor distal vessel quality on percutaneous coronary intervention for chronic total occlusion.

The technical outcome of poor distal vessel quality (PDV) on chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is yet to be clearly elucidated. PDV has not been evaluated in scoring systems. We examined 193 consecutive CTO-PCIs performed in January 2013-December 2017. The endpoint, including the technical outcomes in these patients between with and without PDV, was analyzed. Moreover, we re-evaluated the predictors for CTO-PCI difficulty according to Japan-CTO score. Out of 193 CTO-PCIs, 181 (93.8%) achieved technical success [including 101 (55.8%) with and 80 (44.2%) without PDV]. In patients with and without PDV, the success rates of guidewire crossing using only the antegrade technique were 46.5% vs. 83.8%, respectively (p < 0.0001) and using the retrograde approach were 53.5% vs. 16.3%, respectively (p < 0.0001). Moreover, there were 56 non-interventional collateral channels in 181 patients. The successful rate of primary antegrade approach was significantly lower and the rate of a rescue retrograde approach was significantly higher with PDV (37.2% vs. 62.8%, 76.9% vs. 23.1%, respectively; p < 0.0119). Significant predictors associated with successful guidewire crossings of ≤ 30min included blunt stump, calcification, bending, occlusion length ≥ 20mm, retry lesion following Japan-CTO score, and PDV (p < 0.05, all). Multivariate analyses demonstrated that blunt stump, calcification, bending, retry lesion, and PDV were independent predictors of unsuccessful guidewire crossing of ≤ 30min (odds ratio [OR] 0.31, 95% confidence interval [CI] 0.13-0.71, p = 0.0039; OR 0.34, 95% CI 0.16-0.71, p = 0.0035; OR 0.17, 95% CI 0.05-0.60, p = 0.0034; OR 0.18, 95% CI 0.06-0.54, p = 0.0008; and OR 0.19, 95% CI 0.09-0.41, p < 0.0001, respectively). PDV could affect the technical outcome of CTO-PCI.

Treatment of complex intracranial pathologies with transcirculation endovascular approaches.

The breadth and complexity of neurovascular pathologies treated with endovascular neurosurgery has expanded dramatically in recent years. Many aneurysms remain difficult to treat safely. Transcirculation (contralateral and/or retrograde) approaches through the circle of Willis are useful alternatives for treating challenging lesions endovascularly. Here, we present a series of patients treated with unconventional transcirculation techniques. A total of six patients were treated: four patients with five aneurysms, one patient with an MCA stroke, and one patient with a meningioma requiring preoperative embolization were initially thought not to be amenable to endovascular treatment. The decision was made to treat these patients with transcirculation approaches. All patients were treated by one interventionist. One aneurysm was located in the cavernous internal carotid artery (ICA), one in the vertebral artery, two in the paraclinoid ICA, and one in a cerebellar AVM feeder vessel were treated. Five of six patients (83%) made a full neurologic recovery. Three aneurysms were treated to complete occlusion, one aneurysm was left with small residual neck filling, and one aneurysm was not able to be treated. One patient underwent mechanical thrombectomy of a middle cerebral artery (MCA) embolus and MCA filling was restored after treatment. One patient underwent complete embolization of the deep vascular supply of a meningioma. Although many neurovascular pathologies remain unsuitable for endovascular treatment, transcirculation approaches can allow for safe, successful treatment of challenging lesions in select patients.

Analysis of failure factors in retrograde wire-guided intervention for chronic total occlusion

This study aims to investigate failure factors in retrograde wire-guided cannulation (retrograde approach) for the treatment of coronary chronic total occlusion (CTO). Data of 285 patients treated for CTO using retrograde approach in the General Hospital of Shenyang Military Region from August 2004 to May 2016 were collected. The average age of the 285 patients was 63.89 ± 11.3 years old. Multivariate analysis revealed that the operation risk factors include the number of diseased vessels, collateral circulation, as well as whether anterograde intervention for CTO target vessels was previously performed (OR = 0.875, 95% CI = 0.779-0.940, P= 0.026) and whether other vessels were intervened (OR = 22.372, 95% CI = 2.059-243.031, P= 0.011). Based on the present study, the success rate of retrograde approach for CTO was negatively correlated with the number of diseased vessels and collateral circulation. It was furthermore of importance whether anterograde intervention for CTO target vessels was previously performed and whether other vessels beside CTO vessels were intervened, which were also risk factors.

Endovascular Treatment of Long Superficial Femoral Artery-Chronic Total Occlusions Using the Gogo Catheter With IVUS Via a Popliteal Puncture Method Is Effective, Safe, and Useful.

We aimed to investigate the usefulness of inserting a 6Fr sheath guided by duplex ultrasonography via a popliteal artery puncture. We also aimed to demonstrate endoluminal tracking using a retrograde approach using the Gogo catheter with intravascular ultrasound (IVUS). The bidirectional approach is useful for increasing the success rate of the procedure for long superficial femoral artery-chronic total occlusions (SFA-CTOs). However, this procedure becomes somewhat complicated. Since the proximal blood vessel diameter is clearly larger than the distal end of the CTO and the body surface duplex guide can also be used in the proximal part, it is easier to introduce a retrograde guidewire (GW) into the proximal end. We performed endovascular treatment for long SFA-CTOs with a Gogo catheter + IVUS guide in 31 consecutive cases (male 20/female 11; mean age, 75.6 ± 7.6) from May 2017 to November 2018. We advanced the IVUS until the true lumen could be confirmed and advanced the Gogo catheter toward the IVUS for reinforcement. We attempted to approach the long CTO by repeating this procedure. We named this procedure the GIP method (GIP: Gogo catheter with IVUS via a popliteal puncture). Hemostasis of the popliteal artery was achieved using a commercially available compression hemostatic kit (Tometa-kun, XEMEX, Japan). Successful revascularization was achieved in all cases (in 2 cases, a femoral artery puncture was added, and a bidirectional approach was used, and in 1 case, a CROSSER system was used). On average, the fluoroscopy time was 42.2 ± 30.4 minutes, radiation dose 93.7 ± 78.7 mGy, and amount of contrast medium used 15.0 ± 9.6 mL. The procedure time was defined as from the start of the popliteal artery puncture to the time the GW passed through the CTO lesion, including the posture transformation time from prone to the supine position. The procedure time was 42.1 ± 40.2 minutes. There were no major adverse events or other major complications, such as a distal embolism, rupture of the CTO lesion, arteriovenous fistula, or major hematoma requiring a transfusion or surgical treatment. Only 2 small hematomas occurred at the popliteal artery puncture site. The patients were treated conservatively and were discharged as usual. Endovascular treatment of long SFA-CTOs via the popliteal approach was effective and safe. Using the GIP method to address long SFA-CTOs is recommended.

Morbidity of Retrograde Flexible Ureteral Approach for Pyelo-Caliceal Stones - A Retrospective Review of 4500 Procedures.

Introduction: The retrograde flexible ureteroscopic approach is an effective and relatively safe procedure. The aim of this study was to retrospectively evaluate the safety of retrograde flexible ureteroscopic approach in patients with pyelo-caliceal stones on a significant number of cases. Material and method: We retrospectively evaluated 4500 procedures of flexible retrograde ureteroscopic approach for pyelocaliceal lithiasis, operated in two centers. The complications associated with this approach were retrospectively evaluated and data was stratified according to Clavien- Dindo classification. Results: Intraoperative incidents occurred during 5.2% of the procedures. Overall complications occurred in 18.9% of the procedures. Around two thirds of them were septic complications, the use of ureteral access sheath proving to be a protective factor against them. Most of the complications were mild. In 4.8% of the cases in which ureteral access sheath was used, we encountered grade 2 and 3 ureteral wall lesions. Conclusions: Most of the complications associated with retrograde flexible ureteroscopic approach are mild, regardless the type of flexible ureteroscope used. Reduced pressure in the pyelo-caliceal system is important to maintain the complications rate low, both septic and non-septic.

Management of a case of root resorption: A retrograde approach using biomaterial

Management of a case of root resorption: A retrograde approach using biomaterial

Indications for partial superficial parotidectomy for benign parotid gland tumors using the retrograde approach.

A recent systematic review and meta-analysis suggest that retrograde parotidectomy is a safe procedure with no significant difference in facial nerve paralysis rates when compared to anterograde parotidectomy. The aim of the current study was to establish indications for partial superficial parotidectomy using the retrograde approach. To this end, the two surgical techniques were compared in terms of postoperative facial nerve paralysis, tumor size, location of the tumor, and surgical time. For tumor diameters of 30 mm or less, mean surgical time in the retrograde parotidectomy group was significantly shorter than in the anterograde parotidectomy group (p < 0.05). Our study indicates that retrograde parotidectomy may be more effective than anterograde parotidectomy for partial superficial parotidectomy for benign parotid tumors of 30 mm or less.

Biomechanical Comparison of Anterograde and Retrograde Lesser Trochanter Avulsion Repair.

Background:Lesser trochanter avulsions are rare injuries in adolescents. Severe cases with relevant fragment displacement can be treated surgically. However, no standard approach is available in the literature. Operative techniques are presently limited to anterograde fixations. A new retrograde approach to reduce operative difficulty and postoperative morbidity has been proposed. So far, no biomechanical comparison of these techniques is available.Hypothesis:Retrograde repair of the lesser trochanter with a titanium cortical button will produce superior stability under load to failure and similar displacement under cyclic loading compared with anterograde fixation with titanium suture anchors.Study Design:Controlled laboratory study.Methods:Sixteen paired hemipelvic cadaveric specimens (mean age, 62.5 ± 10.7 years) were dissected to isolate the lesser trochanter and iliopsoas muscle. After repair of a simulated lesser trochanter avulsion, specimens were tested under cyclic loading between 10 and 125 N at 1 Hz for 1500 cycles before finally being loaded to failure at a rate of 120 mm/min in a material testing machine. Motion tracking was used to assess displacement at the superior and inferior aspects of the iliopsoas tendon under cyclic loading.Results:Load to failure was significantly greater for the retrograde repair compared with the anterograde repair (1075.24 ± 179.39 vs 321.85 ± 62.45 N; P = .012). Mean displacement at the superior repair aspect (retrograde vs anterograde: 3.29 ± 1.84 vs 4.39 ± 4.50 mm; P = .779) and mean displacement at the inferior aspect (3.54 ± 2.13 vs 4.22 ± 4.48 mm; P = .779) of the iliopsoas tendon did not significantly differ by the type of repair. Mode of failure was tendon tearing by the sutures for each retrograde repair and anchor pullout for each anterograde repair.Conclusion:Surgical repair of lesser trochanter avulsion fractures with retrograde fixation using a titanium cortical button demonstrated superior load to failure and similar displacement under cyclic loading compared with anterograde fixation using suture anchors.Clinical Relevance:The retrograde approach provides a biomechanically validated alternative to other surgical techniques for this injury.

Unusual anatomical variations in plantar metatarsal arteries and plantar arterial arch with surgical significance

Background: Critical limb ischemia (CLI) has been a burden on society where revascularization of arteries is the first line of treatment. If the antegrade approach is not possible, retrograde approach through pedal–plantar loop can be done, resulting in better prognosis. For the same reason, assessment of blood vessels of foot in general is practiced before any intervention. Having information about normal anatomy and anatomical variants of these blood vessels could be of great help to the interventionist to reduce the postoperative complications. Context: The authors studied formation of plantar arterial arch, normal anatomy, and anatomical variations in plantar metatarsal arteries (PMTAs) regarding their origin in 50 formalinized adult cadaveric feet. Results and Conclusion: Variations in formation of plantar arterial arch as predominant lateral plantar artery supplying to most of the PMTAs were noted. Common stump of origin for the first and second, then for second and third, and also for the third and fourth PMTAs was found. In two feet, we found common stump of origin for the first PMTA and first dorsal metatarsal artery originating from deep plantar arch. Medial branch from medial plantar artery joined the first PMTA to supply the great toe deep to the transverse metatarsal ligament. In about 28% of specimens, the foot length was ranging from 21.1 cm to 22 cm and the distance between the plantar arterial arch and the posterior margin of heel was ranging between 12 and 13.5 cm. Fibular plantar marginal artery was present in all specimens. Implications: In the retrograde approach for the revascularization in cases with CLI, most of the surgeons are trying the approach through plantar pedal loop or direct puncture of metatarsal arteries. Data collected on plantar metatarsal normal anatomy and anatomical variations can be kept in mind while doing any intervention with better prognosis.

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.

Outcomes of Transpedal Arterial Access Hemostasis Using a Radial Hemostatic Band.

There is increasing burden of peripheral arterial disease (PAD) in the United States. Despite advancements in endovascular therapy, there have been significant limitations in invasive interventions aimed at revascularization. The transpedal tibial artery retrograde approach has been described as an alternative access for patients with complex disease requiring dual access or failed revascularization via conventional common femoral artery access. In this study, we examined the safety and efficacy of a radial hemostatic band to achieve hemostasis post procedure without compromising the integrity of the accessed tibial artery. This study included 20 patients with PAD requiring endovascular revascularization on whom the RadAR band device (Advanced Vascular Dynamics) was applied for postprocedure hemostasis following transpedal access between December 2011 and May 2014. All patients underwent routine postprocedure ankle-brachial indices (ABIs) following hemostasis to determine outcomes of the overall ABI and that of the accessed pedal artery. Mean patient age was 77 years and mean patient weight was 80.9 kg. Mean follow-up was 11 months post procedure. Lesions were located as follows: 3 popliteal, 13 superficial femoral, 3 posterior tibial, and 1 anterior tibial. Nine procedures were performed on the left leg and 11 on the right leg. All patients received heparin as anticoagulation, with a targeted activated clotting time between 250-300 seconds. Access was made into the posterior tibial in 15 patients and in the anterior tibial in 5 patients. RadAR band was deployed in a fashion similar to its deployment on the radial artery. Hemostasis was achieved in all 20 cases without complication. Postprocedure ABI and pedal-brachial index (PBI) improved significantly compared with the preprocedure values. There was an average improvement of approximately 50% in ABIs, improving from 0.59 to 0.88. The PBI also improved from 0.59 before the procedure to 0.87 post procedure. There was, however, no significant difference in ABI or PBI in anterior vs posterior tibial artery access patients. Transpedal tibial arterial access is an effective technique for revascularization in the lower extremity, and postprocedure access-vessel hemostasis and patency are reliably and safely achieved using a hemostatic band device.

Functional outcome of modified technique of intramedullary fixation of diaphyseal humeral fractures

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; The aim of this study was to evaluate the functional outcomes with intramedullary fixation using flexible nails and to follow up for any other complications.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; Study was a prospective study in Lata Mangeshkar Hospital, Nagpur during 2014 to 2016. All the patients enrolled in the study were briefed about the nature of the study. All cases in this series were operated by combined antegrade and retrograde approach.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; Total of 30 patients of closed diaphyseal humeral fractures was studied. Maximum i.e., 16 (53.33%) were in the age range of 21-40 years, followed by 10 (33.33%) patients in the range of 41-60 years. 21 (70%) cases had fracture union between 10-16 weeks with a score&lt;strong&gt; &lt;/strong&gt;of 8 points, followed by 8 (26.67%) patients with fracture union duration&lt;strong&gt; &lt;/strong&gt;of less than 10 weeks with a score of 10 points. Only one of the patients landed up with non-union. The mean functional score of patients at 3rd month was 64.03±4.99, 9th month was 73.46±2.56. 86.66% patients had good to fair outcome, 3.33% patient each had excellent and poor outcome.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Comparing results of our study with other studies, we found that our results are almost comparable but not better than open reduction and plating. Complications encountered in our series are comparatively less compared to those encountered during interlock nailing. The trauma to rotator cuff is minimum and this method is good alternative method. Thus, multiple nailing gives better functional outcomes as compared to locked nail. &lt;/p&gt;

Superficial Parotidectomy by Retrograde approach through Marginal Mandibular Nerve Dissection

Background: Parotid gland is most commonly involved in tumors, comprising about 80% of the salivary gland neoplasms. Majority of parotid tumors are benign in nature, the most common being pleomorphic adenoma. Superficial Parotidectomy is the preferred treatment option, using either anterograde or retrograde approach. The objective of this study was to determine the post-operative facial nerve status and other complications following superficial Parotidectomy by retrograde dissection for benign lesions of parotid gland.Material and Methods: This prospective clinical study included a total of 22 patients who had superficial Parotidectomy by retrograde technique involving marginal mandibular nerve dissection. These patients were studied post-operatively for facial nerve status, Frey’s Syndrome, wound infection and salivary fistula.Results: Out of a total of 22 patients, 54.54% developed temporary facial palsy on ipsilateral angle of mouth and all of them recovered by the end of 3 months post-surgery. Two patients (9.09%) developed salivary gland fistula and both of them healed spontaneously within two weeks. Frey’s Syndrome and wound infection were not seen in any of the patients included in the study. Histopathology of these lesions revealed pleomorphic adenoma (n=20) and Warthin’s tumor (n=2), respectively.Conclusion: The use of marginal mandibular nerve as a landmark for retrograde dissection of facial nerve in superficial Parotidectomy is a reliable method to ensure lower percentage of facial nerve injury and associated complications.

Double-balloon enteroscopy for retrieving retained small-bowel video capsule endoscopes: a systematic review

Background and aim: Capsule retention is the most common adverse event associated with video capsule endoscopy. The use of double-balloon enteroscopy-assisted capsule endoscope retrieval has been increasingly reported in recent years. However, evidence is limited regarding its success rate, associated factors, and subsequent clinical outcomes.Methods: A systematic review of relevant studies published before January 2019 was performed. Successful retrieval rate and associated factors, rate of endoscopic balloon dilation, and outcomes after double-balloon enteroscopy were summarized and pooled.Results: Within 154 associated original articles, 12 including 150 cases of capsule retrieval by double-balloon enteroscopy were included. The estimated pooled successful retrieval rate was 86.5% (95% confidence interval, 75.6–95.1%). Anterograde approach and capsules retained in the jejunum or trapped by malignant strictures were associated with a higher successful retrieval rate than the retrograde approach (62/83 [74.7%] vs. 10/38 [26.3%], p < .001) and capsules retained in the ileum (41/41 [100.0%] vs. 43/58 [74.1%], p < .001) or trapped by benign strictures (21/21 [100.0%] vs. 65/83 [78.3%], p = .043). Endoscopic balloon dilation was performed in 38.8% (95% confidence interval, 22.3–56.3%) of patients with benign strictures. Two perforations (1.3%) were reported as severe adverse events after double-balloon enteroscopy. A significantly lower surgery rate was found among cases with successful video capsule removal compared with unsuccessful cases (7.2% vs. 38.5%, p = .002).Conclusions: Double-balloon enteroscopy is feasible and safe for removing retained video capsule endoscopes, and its use could decrease the need for surgery in patients with benign strictures and facilitate subsequent surgery in patients with malignant strictures.

Ultrasound-Guided Totally Tubeless Mini-Percutaneous Nephrolithotomy for a Completely Excluded Caliceal Diverticulum Associated with Challenging Anatomy.

Mini-percutaneous nephrolithotomy (mini-PCNL) has been described as a safe and effective technique to eliminate stones in patients in whom a less-invasive approach is desired. It was originally developed to treat stones in the pediatric population, but has since been adapted to serve a role in the adult urologic community. This approach has been reported to result in less blood loss and postoperative pain when compared with traditional PCNL. Herein, we present a case in which a recurrent caliceal diverticulum containing stones was managed using a mini-PCNL technique in a patient who previously failed multiple other retrograde endoscopic approaches.

The Impact of Peripheral Artery Disease in Chronic Total Occlusion Percutaneous Coronary Intervention (Insights From PROGRESS-CTO Registry).

The impact of peripheral artery disease (PAD) in patients undergoing chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has received limited study. We reviewed 3999 CTO PCIs performed in 3914 patients between 2012 and 2018 at 25 centers, 14% of whom had a history of PAD. We compared the clinical and angiographic characteristics and procedural outcomes of patients with versus without history of PAD. Patients with PAD were older (67 ± 9 vs 64 ± 10 years, P < .001) and had a higher prevalence of cardiovascular risk factors. They also had more complex lesions as illustrated by higher Japanese CTO score (2.7 ± 1.2 vs 2.4 ± 1.3, P < .001). In patients with PAD, the final crossing technique was less often antegrade wire escalation (40% vs 51%, P < .001) and more often the retrograde approach (23 vs 20%, P < .001) and antegrade dissection/reentry (20% vs 16%, P < .001). Technical success was similar between the 2 study groups (84% vs 87%, P = .127), but procedural success was lower for patients with PAD (81% vs 85%, P = .015). The incidence of in-hospital major adverse cardiac events was higher among patients with PAD (3% vs 2%, P = .046). In conclusion, patients with PAD undergoing CTO PCI have more comorbidities, more complex lesions, and lower procedural success.

Retrograde insertion of the outback reentry device from a tibial artery for complex infrainguinal recanalization

IntroductionRecanalization in an antegrade fashion in complex infrainguinal arterial disease can prove challenging and use of the Outback re-entry device via a retrograde approach may be an option.Case presentationUsing an antegrade approach we were unable to cross the native occluded superficial femoral artery in a patient after two occluded bypasses, with ulcers and was unfit for general anaesthesia.We successfully attempted retrograde re-entry using an Outback device via a phantom segment of the anterior tibial artery. After angioplasty and stenting a satisfactory result was achieved with one artery runoff.ConclusionsAt the 24 months follow up reconstruction was patent and ulcers were healed after 4 months.The outcome of more cases will be decisive for the broader applicability of this technique.

Revascularization of a specific angiosome for limb salvage: does the target artery matter?

BackgroundTo compare clinical outcomes and technical success when direct versus indirect revascularization was achieved after endovascular technique for critical limb ischemia patients with isolated below-the-knee lesions. Fifty patients were included, 34 male and 16 female, their age from 49 to 77 years (mean 63 ±16). All patients were subjected to infra-genicular angioplasty and divided into direct 28 (31 limbs) and indirect groups 22 (24 limbs). Antegrade approach through ipsilateral CFA was used in 48 patients, while retrograde approach through tibiopedal access was used in 2 patients. Diagnostic angiography was done for all cases and duplex ultrasound was used for follow-up.ResultsOne hundred thirty-two lesions were encountered, 46 in the ATA, 43 in PTA, 29 in peroneal artery, and 19 in dorsalis pedis artery. Transluminal approach was done in 47 limbs while subintimal cross was used in 8 limbs. After 1 year follow-up, AFS was 75% in the direct group and 67% in the indirect group. Freedom from MALE was 65% in the direct group and 55% in the indirect group. Freedom from MA was 86% in the direct group and 75% in the indirect group.ConclusionWhen there is a choice of target artery for revascularization, preference should be given to the artery directly feeding the wound’s angiosome.

Retrograde-Assisted Percutaneous Cystolitholapaxy Versus Transurethral Cystolithotripsy With Holmium-YAG Laser: A Retrospective Study.

Introduction: The retrograde approach is a modification that makes the percutaneous cystolitholapaxy (PCCL) a more trendy method, especially in operating rooms with limited facilities. The transurethral approach for bladder calculi lithotripsy by a laser has become popular among urologists. In this study, we investigate the feasibility and safety of retrograde assisted access for PCCL in comparison with transurethral cystolithotripsy by the holmium-YAG laser (Ho: YAG). Methods: According to the type of intervention, the patients were stratified to two matched groups. In the retrograde-assisted percutaneous cystolitholapaxy (RPCCL) group, a Benique was conducted through the urethra into the bladder; palpating the suprapubic region, an about 1.5 cm incision was done over the tip, then an Amplatz sheath was placed over it, treading into the bladder; further cystolitholapaxy was done by a routine order. In transurethral Ho: YAG laser lithotripsy (TULL) via 200 µm fiber vaporize the stone. Results: A total of 124 male patients with the mean age of 50.33±9.64 years and the average stone burden of 3.35±1.07 cm were included in the study. The most common cause of vesical calculi was spinal cord injury. Statistically significant differences were found in terms of the mean operation time in favor of the RPCCL group (P≤0.05) and the mean hospital stay in favor of the TULL group (P≤0.05). The stone-free rate (SFR) was 100% in both methods after a onemonth follow-up. None of the interventions changed to open surgery. There were not any major complications in both methods. Conclusion: RPCCL is a safe and effective method in bladder stone treatment and is applicable in medical centres without Ho: YAG equipment.

The Endorevolution – Going Further in Endovascular Techniques Dedicated to Neuroischemic Diabetic Foot

Introduction: The prevalence of Diabetes Mellitus (DM) is increasing. Diabetic patients have a 15-25% lifetime risk of developing a foot ulcer and its annual incidence can reach 25-30% if arterial disease is present. Diabetic angiopathy is a unique vascular disease that has predilection for below-the-knee arteries. Endovascular techniques have been revolutionizing the revascularization of neuroischemic diabetic foot (NIDF) patients, showing consistently high limb salvage rates.In addition, the survival of NIDF patients reaches 50% at 5 years after revascularization and limb salvage, but decreases to 50% at 2 years after a major amputation. Methods: Retrospective institutional review of consecutive patients requiring endodistal revascularization (January 2010 - December 2018). The aim of the present study is to report our experience concerning NIDF patients who underwent tibial arteries revascularization. The primary outcomes were to evaluate the technical success, the limb salvage, the rate of major and minor amputation and the global survival of this population. Results: This study included 373 patients, which corresponded to 540 limbs. The mean age was 70,8 years-old; 66,2% were men, with a mean time of diagnosed diabetes of 15 years. The comorbidities presented were hypertension (81%), hypercholesterolemia (44%), chronic renal disease (31,9%; of those 42,8% in hemodialysis) and smoking (20,1%).Isolated rest pain was present in 4,6% of the patients and foot ulcer in 95,4%. The iliac sector was concomitantly treated in 0,9% of the procedures and the femoro-popliteal sector in 62,6%. Femoral antegrade approach, was obtained in 90,5% of the procedures. The retrograde distal approach was made when the anterograde revascularization failed to cross the occlusion (7,6% of procedures). Direct revascularization according to the respective angiosome was obtained in 59,1% of the cases. In the femoro-popliteal sector, PTA was performed in 49,7% of the procedures (2,4% with DEB) and recanalization and stenting in 47,9%. Tibial arteries stenting was performed in 2% of procedures, as a bail-out technique. The technical success (defined as crossing the occlusion and recanalization to a pedal vessel) was achieved in 85,5% of the procedures. The median follow-up (FU) time was 8 months (mo).During FU, 13,6% of patients was submitted to major amputation and 35,1% to minor amputation. The major amputation free-survival rate was 81,7% at 12 mo and the rate of complete healing at 12 mo was 66,9%. The 12 mo global survival was 81%. Direct angiossomic revascularization (p=0,03) and the number of tibial arteries recanalized (p=0,01) were associated with higher rates of limb salvage and healing. In the opposite side, there was association between the increasing of renal dysfunction and the absence of healing (p=0,04). The endovascular reintervention rate was 21,3% and the median time was 225 days after the first procedure. Conclusion: With the introduction of devices specifically designed for the treatment of below-the-knee vascular disease, recanalization of the tibial and pedal arteries has become technically feasible. The results of this study on endodistal revascularization, highlights the need to prioritize investigation and revascularization in NIDF to improve the outcome of foot ulcer, giving the possibility of salvaging a greater number of limbs. Disclosure: Nothing to disclose