Distal Retrograde Access for Infrainguinal Arterial Chronic Total Occlusions: A Prospective, Single Center, Observational Study in the Office-Based Laboratory Setting

Abstract

Objective: To assess the safety and efficacy of retrograde arterial recanalization of infrainguinal CTOs in the OBL setting. Methods: Consecutive patients who underwent interventions for lower extremity CTOs in the OBL setting by a single vascular surgeon were evaluated (January 2013-November 2017). If antegrade crossing was not possible, then a retrograde distal approach was used. Patient characteristics, CTO location, procedural time, contrast, anticoagulation and radiation doses and costs were recorded. Post-procedural complications were documented on post-procedure day 1 and 10-14 days post procedure. Three groups were compared: group 1—antegrade approach for femoropopliteal CTOs; group 2—antegrade approach for tibial CTOs, and; group 3—retrograde approach for femoropopliteal and tibial CTOs. Results: Two hundred and thirty-seven patients were studied. In 39 (16.5%), the lesions could not be crossed. A successful antegrade approach was used in 185 of them, of which 69% ( group 1, n = 128) patients had femoropopliteal CTOs and 31% ( group 2, n = 57) had tibial CTOs. Fourteen patients (5.9%, group 3) were treated by retrograde distal approach. Group 3 patients received higher contrast doses than groups 1 and 2 ( p = 0.01). However, patients in groups 1 and 2 received similar contrast doses. Group 3 patients had the highest operative time and treatment costs followed by group 1 and then group 2 ( p = 0.01). Three femoral pseudoaneurysms were noted in group 1, and 2 in group 2. No complications were seen in group 3. Conclusions: Although the operative times, costs, radiation and contrast dose are higher with retrograde arterial access, it represents a safe and effective method for the crossing of CTO infrainguinal lesions in an ambulatory venue.

Endovascular treatment of femoro‐popliteal occlusions with retrograde tibial access after failure of the antegrade approach

“…Previous investigations have observed a similar low complication rate associated with distal vascular access sites. [11][12][13][14]33,34,36,45 The rate of VASCs was also comparable to other | 1115 published studies in the endovascular field related to both femoral and radial access. [46][47][48][49][50] Patel et al 51 compared the transradial and tibio-pedal approach in femoro-popliteal CTOs, highlighting higher major adverse events at 30 days in the transradial access arm (5% vs. 0%).…”

“…Htun et al 13 observed a shorter fluoroscopy time, as expected, when retrograde tibio‐pedal access is performed as the primary approach. The dose‐area product and the cumulative air kerma don't differ from that of other investigations in this field in which different distal access sites were used 12,14 . Retrograde crossing of femoro‐popliteal occlusions with tibial access is associated with similar procedure duration, fluoroscopy time and radiation exposure, compared to other distal vascular access sites.…”

“…In claudication patients with limited run‐off, progression to critical limb ischemia may occur. It has been speculated that retrograde access of proximal arteries would minimize the chances of vessel occlusion given their larger lumen; furthermore, minimizing the number of punctures of the vascular access site and achieving patent hemostasis could reduce the risk of VASCs 12,15,44 …”

“…12,14 Giusca and Leon which different distal access sites were used. 12,14 Retrograde crossing of femoro-popliteal occlusions with tibial access is associated with similar procedure duration, fluoroscopy time and radiation exposure, compared to other distal vascular access sites. The administered dose of contrast medium was not higher than that recorded in other studies for the antegrade crossing of femoropopliteal occlusions.…”

“…The failure rate can be up to 20% 11 . In cases of failure of the antegrade approach, crossing the lesion in a retrograde fashion represents a safe and effective alternative 9,12–15 . The distal end of a chronic total occlusion (CTO) is often tapered with a softer cap, resulting in easier penetration of the guidewire compared to the proximal cap 16 .…”