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Background
Retrograde pedal access allows the treatment of tibial occlusive lesions when standard techniques fail. We report outcomes in patients with Rutherford class IV and V limb ischemia, who were otherwise not candidates for revascularization thru an antegrade access or tibial bypass.
Methods
A retrograde pedal access was selectively chosen when a popliteal or tibial lesion could not be crossed via an antegrade approach. Retrograde pedal access was performed under ultrasound-guidance using a 4-Fr micropuncture sheath. All interventions were performed in a sheathless fashion using a 0.014” ‘bareback’ wire as support for a 2 mm balloon catheter to cross tibial chronic total occlusions. Routine anticoagulation and dual-antiplatelet therapy was used peri-procedurally. Antegrade access was used to treat any lesion that required a stent placement, after snaring the retrograde through an antegrade catheter. Outcomes analyzed were limb salvage rate, periprocedural complications and mortality.
Results
From July 2010 thru August 2013, 764 lower extremity angiograms were done; of these, 13 cases were retrograde pedal access (mean age was 71.4 +/- 12.4 years, 9 men). There was high prevalence of diabetes (77%; 10/13), chronic renal insufficiency (stages III - V; 69%, 9/13), and previous contralateral major amputation (38%; 5/13). Indications for a retrograde pedal revascularization were Rutherford chronic limb ischemia class IV (15%; 2/13) and class V (85%; 11/13). Technical success rate was 69% (9/13); popliteal (2/13) and tibial (13/13) vessels were intervened with angioplasty alone (10/13) via a retrograde approach and with angioplasty/stent placement (3/13). Peri-procedurally, there was one myocardial infarction, no local complications, worsening renal insufficiency or deaths. At a mean follow-up of 13.4 +/- 10.3 months, the limb salvage rate was 77% (10/13) [Figure]. There was a high mortality rate on follow-up (23%; 3/13) occurring at median 6 +/-4 months.
Conclusions
Retrograde pedal access for limb salvage in high-risk patients is feasible and safe with acceptable limb salvage rates at intermediate follow-up. Appropriate candidates are those who have failed an antegrade intervention and are poor candidates for a tibial bypass. Future studies should test whether this mode of revascularization has favorable limb salvage rates in larger patient populations.