When Antegrade Access Fails: An Update on Our Experience With Utilizing a Retrograde Arterial Access in the Management of Infrainguinal Occlusive Disease
Mary Kathryn Huddleston, MD, Charles S. Joels, MD, L. Richard Sprouse, MD.
University of Tennessee Health Science Center, Chattanooga, TN, USA.
Objective: The objective of this review is to describe technical success and short-term outcomes following a retrograde approach for infrainguinal therapeutic revascularization. Retrograde arterial access (RTR) techniques allow entry into the distal target vessel to aid in recanalization of occlusions when endovascular antegrade access fails.
Methods: A lower extremity intervention vascular registry was queried to identify patients in which a RTR was performed when an infrainguinal occlusion could not be managed through an antegrade approach. Demographics, surgical indication, comorbidities, rates of procedural success, limb salvage rates, periprocedural complications, and mortality were collected. Access of the tibial, peroneal, pedal, or popliteal artery was obtained after anesthetizing the skin with a micropuncture sheath under ultrasound. Lesions successfully crossed were then treated either directly via the RTR, or via subintimal arterial flossing with antegrade-retrograde intervention.
Results: From February 2012 to May 2016, 101 cases were identified, (40 office and 61 hospital) in which a RTR was performed. Mean follow up was 6 months. Preoperative indications included Rutherford 3 (14), Rutherford 4 (30), and Rutherford 5 (57). A variety of tibial (25) and SFA/popliteal (116) lesions were treated.
The crossing success rate with RTR was 86% (87 of 101). Of these, 77% of patients experienced improvement in post-operative Rutherford scores. There were 6 major amputations within the successful crossings. Two of these were secondary to acute embolization. The other four were secondary to severe, chronic disease and inability to affect improvement with endovascular intervention.
Technical failures were defined as inability to cross the lesion from a RTR or failure to connect with the antegrade access. Of these 14 failures (14%), three remained chronic Rutherford 5, but with healing wounds, and three required below knee amputation (BKA). One of the patients who required BKA later developed a stump infection, and ultimately died secondary to sepsis. This was the only death in our series for a 1% mortality rate.
Conclusions: Retrograde approach for extensive infrainguinal occlusive disease in high-risk patients for limb salvage continues to be a safe and feasible strategy with excellent limb-salvage and complication rates at follow-up. This technique can be expanded to both office and hospital locations offering an endovascular option for revascularization to patients who are not otherwise bypass candidates for limb salvage
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