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Midterm Outcomes After Pre-arteriotomy Guidewire Access (PAGA) with Antegrade Recanalization in Patients with Extensive Aortoiliofemoral Occlusive Disease without the use of a Re-entry Device
Carlos F. Bechara, MD MS, George Pisimisis, MD, Neal R. Barshes, MD MPH, Panos Kougias, MD, Peter H. Lin, MD.
Baylor College of Medicine, Houston, TX, USA.

Introduction: A pre-arteriotomy guidewire access (PAGA) was described to treat bulky iliofemoral occlusive disease. A wire is passed first from the groin into the aorta prior to the arteriotomy to increase technical success. Achieving retrograde intraluminal access in extensive aortoiliofemoral (AIFOD) occlusive disease can be a challenge. We modified the PAGA technique to successfully recanalize extensive aortoiliofemoral occlusion performed with adjunctive femoral artery reconstruction as an alternative to extra-anatomic bypass in high risk patients for aortobifemoral bypass (ABF).
Methods: We approach these cases via a left brachial approach and groin cut down. Once brachial access is obtained, the patient is systematically heparinized. Then a 90-cm destination sheath is placed in the distal aorta. A stiff glidewire and a guide catheter are used to recanalize the chronic AIFOD. The wire is passed in an antegrade fashion across the AIFOD all the way towards the femoral head. A femoral arteriotomy is done to capture the wire thus establishing access from the groin into the patent aorta. External iliac artery and Femoral artery endarterectomy is performed around the wire. The wire is passed through the patch prior to completing the patch angioplasty. Once femoral revascularization is done, a sheath is placed over the wire, and retrograde iliac stenting is performed to the level above the patch to avoid crossing the inguinal ligament.
Results: This procedure has been performed in 18 patients (13 critical limb ischemia, 5 claudicants) with 94.4 % technical success without the use of a re-entry device. Fourteen (77.8%) patients required femoral endarterectomy with patch angioplasty, while 4 required interposition graft. Ten (55.5%) patients were done under spinal anesthesia. All patients had significant cardiopulmonary comorbidities and 5 had multiple abdominal surgeries. One (5.5%) patient had a superficial wound infection treated with oral antibiotics. One (5.5%) patient died within 30 days (massive MI), and one patient required an axillobifemoral bypass at 6 months for acute stent occlusion. The remaining 17 patients are symptom free with patent stents at a mean of 16.5 months (12-22 months).
Conclusion: Modified PAGA can be used to safely revascularize high-risk patients with extensive AIFOD with acceptable complication rate and patency. This procedure is currently offered to patients with aortoiliofemoral disease, not candidates for ABF, instead of an extra-anatomic bypass.


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