Retrograde Revascularization of Tibial Arteries in Patients with Critical Limb Ischemia: Plantar-Arch Versus Transpedal Approach

Abstract

Purpose: To compare retrograde plantar-arch and transpedal-access approach for revascularization of below-the-knee (BTK) arteries in patients with critical limb ischemia (CLI) after a failed antegrade approach. Materials and Methods: Retrospectively we identified 811 patients who underwent BTK revascularization between 1/2014 and 1/2020. In 115/811 patients (14.2%), antegrade revascularization of at least 1 tibial artery had failed. In 67/115 (58.3%), patients retrograde access to the target vessel was achieved via the femoral access and the plantar-arch (PLANTAR-group); and in 48/115 patients (41.7%) retrograde revascularization was performed by an additional retrograde puncture (TRANSPEDAL-group). Comorbidities, presence of calcification at pedal-plantar-loop/transpedal-access-site, and tibial-target-lesion was recorded. Endpoints were technical success (PLANTAR-group: crossing the plantar-arch; TRANSPEDAL-group: intravascular placement of the pedal access sheath), procedural success [residual stenosis <30% after plain old balloon angioplasty (POBA)], and procedural complications limb salvage and survival. Correlations between calcification at access site/tibial-target-lesion and technical/procedural-success were tested. Results: Technical success was achieved in 50/67 (75%) patients of the PLANTAR-group and in 39/48 (81%) patients of the TRANSPEDAL-group (p=0.1). Procedural success was obtained in 23/67 (34%) patients of the PLANTAR-group and in 25/48 (52%) patients of the TRANSPEDAL-group (p=0.04). In 14/49 (29%) cases with calcification at the pedal–plantar loop, technical success was not achieved (p=0.04), and in 33/44 (75%) patients with calcification at the tibial-target-lesion, procedural success was not attained (PLANTAR-group) (p=0.026). In the TRANSPEDAL-group, correlations between calcification at access site/tibial-target-lesion and technical/procedural-success were not observed (p=0.2/p=0.4). In the PLANTAR-group, minor complications occurred in 13/67 (19%) and in the TRANSPEDAL-group in 4/48 patients (8%) (p=0.08). Limb salvage at 12 (18) months was 90% (82%) (PLANTAR-group; 95%CI 15.771–18.061) and 84% (76%) (TRANSPEDAL-group; 95%CI 14.475–17.823) (Log-rank p=0.46). Survival at 12 (18) months was 94% (86%) (PLANTAR-group; 95%CI 16.642–18.337) and 85% (77%) (TRANSPEDAL; 95%CI 14.296–17.621) (Log-rank p=0.098). Conclusion: Procedural success was significantly higher using the transpedal-access approach. Calcifications at pedal–plantar loop and target-lesion significantly influenced technical/procedural failure using the plantar-arch approach. No significant difference between both retrograde techniques in terms of feasibility, safety, and limb salvage/survival was found.

Balloon-Assisted Retrograde Puncture of Distal Vessels in Patients Unsuitable for a Conventional Transpedal Approach

“…This fact becomes more apparent in cases with calcification of the occluded target vessels, increasing the likelihood of procedural failure. 8 The balloon-assisted retrograde puncture helps to overcome this scenario since it turns a plantar loop "indirect" approach of the opposite artery into a "direct" transpedal access. Stahlberg et al 8 have recently reported a significantly higher procedural success rate of the transpedal-access compared with the plantar arch approach.…”

“…8 The balloon-assisted retrograde puncture helps to overcome this scenario since it turns a plantar loop "indirect" approach of the opposite artery into a "direct" transpedal access. Stahlberg et al 8 have recently reported a significantly higher procedural success rate of the transpedal-access compared with the plantar arch approach. One reason for this could be the shorter distance to the target lesion with increased pushability, since remarkably the technical success rate in both groupsdefined as access to the distal cap of the occlusion-did not differ significantly.…”

“…This fact becomes more apparent in cases with calcification of the occluded target vessels, increasing the likelihood of procedural failure. 8…”