Outcomes of Peripheral Vascular Interventions via Retrograde Pedal Access for Chronic Limb-Threatening Ischemia in a Multicenter Registry

Abstract

Purpose: To describe the use and 1-year outcomes of retrograde pedal access during peripheral vascular interventions (PVI) for chronic limb-threatening ischemia (CLTI). Materials and Methods: From October 2016 to September 2017, 159 patients (mean age 71±10 years; 112 men) undergoing PVI via retrograde pedal access were enrolled in the multicenter Vascular Quality Initiative (VQI) registry. The pedal access approach included retrograde femoral (40%), antegrade femoral (26%), retrograde to antegrade femoral (22%), and pedal only (11%). A comparator group of 1972 patients (mean age 69±12 years; 1129 men) having a contralateral retrograde femoral access was established for propensity matching, which resulted in 156 patients per group. Procedure characteristics, technical success, and access site complications were compared. Major adverse limb events (MALE) and amputation-free survival (AFS) at 1 year were analyzed using the Kaplan-Meier method and Cox proportional hazard models to calculate hazard ratios (HR) and 95% confidence intervals (CI). Results: Technical failure was similar for retrograde femoral and pedal access (7% vs 13%, p=0.07). Complications were rare and included access site hematoma (2 vs 5, p=0.32) and target artery thrombosis (0 vs 2) for the femoral vs pedal access groups, respectively. The rates of MALE at 1 year were significantly lower after retrograde femoral access (24%) compared with pedal access (38%; log-rank p=0.01; HR 1.95, 95% CI 1.15 to 3.30). AFS estimates at 1 year were similar: 86% for retrograde femoral and 83% for pedal access (log-rank p=0.37; HR 1.32, 95% CI 0.73 to 2.39), as were major amputation estimates: 10% for retrograde femoral access and 13% for pedal access group (log-rank p=0.21; HR 1.58, 95% CI 0.77 to 3.26). Conclusion: In this analysis of multicenter registry data, retrograde pedal access in patients with CLTI had similar technical success and early complications in comparison with traditional contralateral retrograde femoral access. The rates of MALE were higher after pedal access but AFS was similar, indicating a tradeoff between limb salvage and repeat interventions.

Tibiopedal and distal femoral retrograde vascular access for challenging chronic total occlusions: predictors for technical success, and complication rates in a large single-center cohort

“…The total number of complications (7.6%) was low and mainly related to the access site. In general, this number is similar to previously published data reporting rates of access site complications of up to 13% [14,[31][32][33]. The additional distal access did not increase the number of serious adverse complications (SAR) as only one case suffered from compartment syndrome requiring surgery.…”

“…Among a growing number of dedicated devices for CTO revascularization [5,6], a retrograde approach with tibiopedal access is an increasingly used strategy [5,7]. Since its first usage, the techniques and dedicated material have improved, and technical success rates from 80% up to 100% for lesion crossing have been reported [8][9][10][11][12][13][14]. The application of this technique has been expanded to patients with lifestyle-altering claudication (Rutherford stage III) accompanied by an increase in the technical success rates of treatment [8,9,15].…”

Technical Success and Complication Rates of Retrograde Arterial Access for Endovascular Therapy for Critical Limb Ischaemia: A Systematic Review and Meta-Analysis

“…25,36 The six month survival rate, reported by five studies, was estimated to be 91% (95% CI 80%e98%) of 345 patients. 14,20,25,31,39 During a 12 month follow up, the primary patency rate was 62% (three studies; 95% CI 25%e 93%), 18e20 the TLR rate was 33% (four studies; 95% CI 14%e55%), 13,14,18,32 the limb salvage rate was 82% (seven studies; 95% CI 67%e93%), 20,29,31,32,36,39,41 while major amputations were required in 20% (13 studies; 95% CI 13%e28%) of the patients. 13,14,17,18,20,23,25,29,31,32,36,39,41 One study investigating 40 patients reported an additional 15 minor amputations 12 months after the index procedure.…”

“…Weight -% Zhuang 2020 14 Perry 2020 13 Lai 2019 16 Schmidt 2019 18 Palena 2018 19 Stern 2018 20 Matsumi 2017 23 Affonso 2016 24 Goltz 2016 25 Hanna 2016 26 Tay 2016 29 Walker 2016 30 Sabri 2015 31 Palena 2013 36 Ruzsa 2013 37 Yeh 2011 38 Spinosa 2005 40 Botti anterior tibial and the dorsalis pedis arteries. Distal arterial access and retrograde crossing was achieved in 96% of the cases, while procedural success was 91%, with only a few peri-procedural angiographic complications.…”

The Use of Re-Entry Devices Through Pedal Arterial Access in the Management of Chronic Limb-Threatening Ischemia

“…It is our policy, in order to consider the latter access, that all other methods of revascularization (such as the Sub-Intimal Arterial Flossing with Antegrade-Retrograde Intervention-SAFARI-or the Controlled Antegrade and Retrograde Tracking and Dissection-CART-techniques) need to be exhausted due to the fearing of such complications. In the recent multi-center registry analysis on this topic, Perry and colleagues 14 showed that complications were rare and not significantly different between groin versus pedal access groups, including local hematoma and vessel thrombosis. The rates of major adverse limb events at 1 year were higher after pedal access, but the amputation free survival was similar, possibly, as stated by those authors, the result of a trade off between limb salvage and repeated interventions.…”