Retrograde Transpopliteal Access Is Safe and Effective—It Should Be Added to the Vascular Surgeon's Portfolio

Retrograde Tibio-Pedal Access for Endovascular Interventions for Treating Peripheral Arterial Disease

Retrograde tibio-pedal access represents a feasible method for endovascular revascularization when antegrade methods fail. The article offers an extensive review of retrograde tibio-pedal access, emphasizing the technique and documented outcomes.

A systematic review of the ipsilateral retrograde approach to the treatment of femoropopliteal arterial lesions

OBJECTIVE

The endovascular treatment of femoropopliteal lesions is an integral part of managing peripheral arterial disease. The antegrade approach is the most widely used technique with good evidence for its safety and efficacy. However, crossing a lesion, particularly chronic total occlusions (CTO), can be technically challenging and so the retrograde approach is increasingly used to maximize the chances of procedural success. The objective of this systematic review was, therefore, to assess the safety and effectiveness of the ipsilateral retrograde approach to femoropopliteal lesions.

METHODS

A systematic review conforming to the PRISMA standards was undertaken. MEDLINE, EMBASE, and The Cochrane Register were searched between January 1, 1988, and January 1, 2020. Full-text, English-language, peer-reviewed articles pertaining to peripheral arterial disease, endovascular intervention and access site were included.

RESULTS

A total of 8599 articles were screened, of which 38, involving 1940 patients undergoing 2184 retrograde procedures, were included. The mean number of patients per study was 51.1, with three studies including fewer than 10 and four more than 100 patients. The reported follow-up ranged from 30 days to 3 years, and six articles did not report any long-term outcome data. A retrograde approach was used as the primary access route in 45.% of procedures (648/1438) with relevant data. Primary technical success was achieved in 88% (1920/2184; 64%-100%) with a reported complication rate of 11% (235/2117; 0%-27%). Overall, the quality of evidence was poor, with just seven articles deemed to be of high quality with a low risk of bias. A meta-analysis was not deemed appropriate owing to heterogeneity of data.

CONCLUSIONS

An ipsilateral retrograde approach to femoropopliteal lesions has good primary technical success and a low rate of complications. It has a promising role as a bailout, or even a primary access technique, in complex lesions. Patient positioning, puncture site and technique, lesion anatomy, and the size of catheters and devices used are important considerations to achieve the best outcomes. There remains a paucity of robust evidence for its superiority over traditional antegrade approaches, and further work is required to identify the optimal technique and those patients who would benefit most from the approach.

Trans-popliteal hybrid retrograde technique for revascularization of chronic total occlusions of the superficial femoral artery

OBJECTIVES

We present the technical description and preliminary results of a hybrid approach for the treatment of chronic total occlusions of superficial femoral artery in the setting of critical limb-threatening ischemia (CLTI).

METHODS

A retrospective analysis of selected case series was performed. A trans-popliteal hybrid technique was carried out in seven limbs (six patients). Open exposure of above-the-knee popliteal artery was performed over its maximum calcification zone. After retrograde recanalization and graft-stenting of the entire superficial femoral artery, endarterectomy of the popliteal artery was performed for debulking and widening of the distal landing zone of the endoprosthesis. The latter is included in the bovine patch suture to avoid leaving a segment untreated.

RESULTS

Technical success, haemodynamic and clinical improvement were achieved in all procedures. Median length of treated occlusion was 19.8 cm. After a mean follow-up of 12 months (range 6-26 months), the primary patency was 85.7% (only one asymptomatic occlusion occurred). There were no major cardiovascular or limb adverse events. No re-interventions were required.

CONCLUSION

This less-invasive, one-incision technique is safe and effective for the restoration of in-line flow from groin to ankle, currently recommended in CLTI revascularization. It could be especially useful in highly calcified popliteal artery lesions, hostile groins or those at high risk of infection and in cases of vein absence for bypass surgery.

Retrograde-angioscopy guided wiring technique in chronic total occlusion lead to successful revascularization

Endovascular therapy (EVT) was performed in two cases with chronic total occlusion (CTO) of superficial femoral artery. In these cases, angioscopy was deployed in the backyard of the CTO lesion from popliteal artery retrogradely, then the guidewire was advanced from antegrade. When the wire crossed the distal of the CTO lesion, the wire penetration was clearly visualized by the retrograde-angioscopy. Therefore, wire crossing of CTO into the distal true lumen was certainly confirmed, and EVT was successful. <Learning objective: Angioscopy-guided endovascular therapy for chronic total occlusion was useful not only to evaluate thrombus and plaque in situ visually, but also to successfully perform guidewire crossing.>.

Retrograde Popliteal Access and Balloon Dilatation of Chronic Total Occlusion of Superficial Femoral Arteries

BACKGROUND

The objective of the study was to evaluate the effectiveness of retrograde popliteal access in subjects with chronic total occlusion of the superficial femoral artery.

METHODS

A retrospective review of subjects who underwent balloon dilatation via retrograde popliteal access (RPA) is included. Age, gender, tobacco use, comorbid diseases, body mass index, ejection fraction, claudication distance (0 to 50 meters, 50 to 100 meters and 100 to 150 meters), preoperative Rutherford scale, and Ankle-brachial index (ABI) are noted for each subject. A duplex ultrasound (DUS) was performed preoperatively. The localization side of the lesion (right-left), the length of the atherosclerotic segment, and the localization of the diseased segment (proximal superficial femoral artery [SFA], mid-SFA, distal SFA, popliteal-above the knee) were noted. Subjects were followed for at least one year after the procedure. Subjects were reevaluated in the first, 6th, and 12th months after the procedure. In control subjects, Rutherford class and ABI were noted. A DUS was performed to detect restenosis. The subjects' preoperative Rutherford class and ABI and restenosis degree were compared with their postoperative values.

RESULTS

A total of 93 subjects (75.3% male, 24.7% female; mean age 68.57 ± 8.70 years old) were evaluated. In all 93 (100%) subjects, successful RPA was achieved. Overall, balloon dilatation via RPA was successful in 86 (92.47%) of the 93 subjects. The procedural success rate was 92.47%. The occluded segment was on the right side in 49.5% of the subjects (n = 46) and on the left side in 50.5% (n = 47) of the subjects. The mean length of the lesion was 10.77 ± 2.21 cm, and the average stenosis degree was 95.9 ± 5.05%. The localization of the occluded segment was in the proximal SFA, mid SFA, distal SFA and popliteal above the knee in 45.2%, 50.5%, 25.8% and 10.8% of the patients, respectively.When comparing the successful and unsuccessful groups, target lesion length (10.48 ± 2.01 vs. 14.43 ± 0.79, P < 0.001), mid-SFA localization (n = 40 vs. n = 7, P = 0,012) and claudication distance in the first 50 meters (P = 0,003) were significantly higher in subjects with failed balloon dilatation via RPA. When the Rutherford scale was examined, the mild, moderate, and severe claudication ratios were 23.7%, 29%, and 47.3%, respectively. After the procedure, 61.3% of the cases were asymptomatic, and 38.7% had mild claudication. The change in the Rutherford scale was statistically significant (P < 0,001). When the ABI measurements were examined before procedure, it increased from 0.63 ± 0.08 before to 0.90 ± 0.06 after the procedure, indicating a statistically significant difference (P < 0,001). When Doppler findings were examined, in the successful RPA group, the no-stenosis percentages were 82.6%, 72.1%, and 65.1 at the first, 6th, and 12th month follow-up, respectively. The mean disease-free survival time was 9.80 ± 0.39 months. In the first year, subjects were divided according to stenosis degree. Subjects with less than 50% stenosis were compared with subjects with more than 50% stenosis to detect the preprocedural characteristics that affect the restenosis degree. Tobacco use, chronic obstructive pulmonary disease, hyperlipidemia, chronical renal insufficiency, and popliteal above the knee localization were significantly higher in subjects who had more than 50% stenosis 1 year after the procedure (P = 0.009, P = 0.015, P = 0.044, P = 0.001, and P = 0.017, respectively).

CONCLUSIONS

RPA under DUS guidance is an effective method. RPA has high procedural success rate with low morbidity. Longer target lesion length, mid-SFA localization, and claudication distance in first 50 meters found to be related factors with RPA balloon dilatation failure. Restenosis rates after 12 months of follow-up is low and comparable with literature.

Intraoperative angiography via the popliteal artery: a useful technique for patients in the prone position

OBJECTIVE Intraoperative angiography can be a valuable tool in the surgical management of vascular disorders in the CNS. This is typically accomplished via femoral artery puncture; however, this can be technically difficult in patients in the prone position. The authors describe the feasibility of intraoperative angiography via the popliteal artery in the prone patient. METHODS Three patients underwent intraoperative spinal angiography in the prone position via vascular access through the popliteal artery. Standard angiography techniques were used, along with ultrasound and a micropuncture needle for initial vascular access. Two patients underwent intraoperative angiography to confirm the obliteration of dural arteriovenous fistulas. The third patient required unexpected intraoperative angiography when a tumor was concerning for a vascular malformation in the cervical spine. RESULTS All 3 patients tolerated the procedure without complication. The popliteal artery was easily accessed without any adaptation to typical patient positioning for these prone-position cases. This proved particularly beneficial when angiography was not part of the preoperative plan. CONCLUSIONS Intraoperative angiography via the popliteal artery is feasible and well tolerated. It presents significant benefit when obtaining imaging studies in patients in a prone position, with the added benefit of easy access, familiar anatomy, and low concern for catheter thrombosis or kinking.