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Rouse M, Kawaji Q, Randhawa D, Chin J, Vallabhaneni R, Crowner J. Intraoperative Pedal Pressure Changes Offers Another Quantitative Assessment for Revascularization. Ann Vasc Surg 2024; 104:248-254. [PMID: 38492728 DOI: 10.1016/j.avsg.2023.12.089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 12/02/2023] [Accepted: 12/22/2023] [Indexed: 03/18/2024]
Abstract
BACKGROUND Lower extremity angiography is one of the most prevalent vascular procedures performed, generally via the contralateral common femoral artery. The use of retrograde pedal artery access to perform angiography has long been reserved as a "bail-out" technique to help cross chronic total occlusions that were not amenable from an antegrade approach. Recently, there have been reports and discussions involving increased utilization of pedal access for primary revascularization. The purpose of this study is to describe the outcomes of pedal access as a primary approach and to propose a novel evaluation of distal perfusion changes associated with interventions using direct pressure measurements. METHODS A retrospective observational study evaluating all patients who underwent lower extremity angiography via retrograde pedal access between December 1, 2020, and June 30, 2021, within a single health-care system spanning 3 hospitals was performed. Demographics, comorbidities, procedural indications, and details were all recorded. Hemodynamic measurements were obtained and recorded upon initial pedal access and post intervention with a pressure transducer connected directly to the access sheath. Outcomes were analyzed with paired t-test. RESULTS Twenty-eight angiograms using primary pedal access for endovascular intervention were performed during the study period. Most patients were African American (75%) females (57.1%) with hypertension (89.3%), hyperlipidemia (78.6%), diabetes (85.7%), coronary artery disease (64.3%), and current tobacco users (57.1%). The most prevalent indication for angiography was nonhealing wounds (67.9%). Pedal access was mostly achieved via the anterior tibial artery (79%). Sixty-three vessels were treated during the 28 angiograms (averaging 2.3 vessels per angiogram), most commonly the superficial femoral (27%), anterior tibial (25%), and popliteal (22%) arteries. Balloon angioplasty with or without stenting (98.5%) was predominately performed with an overall technical success rate of 94%. The mean preintervention and postintervention pressures were 36.5 mm Hg (standard deviation [SD] 25.7) and 83.4 mm Hg (SD 19.5), respectively. The mean change in pressure after intervention was 46.9 mm Hg (SD 23.3) (Table 3). There was a statistically significant difference detected between preintervention and postintervention pressure (P < 0.001) (Figure 1). There were no major amputations or adverse cardiovascular events at a mean first follow-up duration of 89 days. Six of the total 28 patients (21.4%) underwent repeat endovascular intervention on the ipsilateral extremity within a median of 45 (interquartile range 22.5-62.3) days. CONCLUSIONS Primary pedal access is a viable option for performing lower extremity angiographic interventions. A significant increase in pedal artery pressure can be observed after angiographic intervention from retrograde pedal artery access. Further studies are necessary to define the clinical prognostic importance of these findings in relation to wound healing rates.
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Affiliation(s)
- Michael Rouse
- Department of Surgery, MedStar Health Baltimore, Baltimore, MD
| | - Qingwen Kawaji
- Department of Surgery, MedStar Health Baltimore, Baltimore, MD.
| | | | - Jason Chin
- Department of Vascular Surgery, MedStar Health, Baltimore, MD
| | | | - Jason Crowner
- Department of Vascular Surgery, MedStar Health, Baltimore, MD
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2
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Nezzo M, Meloni M, Carini A, Carreri B, Nicita F, Garaci F, Morosetti D. Efficacy of retrograde revascularization in diabetic patients with chronic limb-threatening ischemia after a failed antegrade approach. Vascular 2024:17085381241256022. [PMID: 38815574 DOI: 10.1177/17085381241256022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2024]
Abstract
BACKGROUND Chronic limb-threatening ischemia is the end stage of peripheral arterial disease. The revascularization of patients suffering from diabetes mellitus who present chronic total occlusions of below-the-knee vessels can be technically very difficult and sometimes impossible to achieve by performing only an antegrade approach. As regards retrograde recanalization, several studies have investigated the efficacy and safety of this technique in the femoropopliteal axis or in the infrageniculate arterial vessels in patients with advanced atherosclerotic disease. Currently in the literature there are still few studies analyzing the effectiveness of the retrograde approach in the treatment of occlusions of below-the-knee vessels in patients suffering from diabetes mellitus. OBJECTIVES The purpose of the study was to retrospectively evaluate safety, technical success, and clinical outcome of retrograde transpedal/transtibial recanalization in patients suffering from diabetes mellitus. RESEARCH DESIGN This is a retrospective observational monocentric study. SUBJECTS We retrospectively analyzed data over a three-year period (August 2019-September 2022) of patients that underwent revascularization of one or more below-the-knee vessels for chronic limb-threatening ischemia and had a retrograde transpedal/transtibial approach after a failed antegrade transfemoral revascularization. We identified and included in the study 28 out of 352 patients. MEASURES We evaluated clinical comorbidities, Rutherford-Becker classification, Texas classification, and the occluded vessels (only below-the-knee or multi-level occlusions); we then analyzed technical, procedural and clinical success, survival rate, and procedural complications. All patients included in the study underwent a 6 months follow-up. RESULTS Patients belonged to Rutherford-Becker stage V (18) or VI (10), Texas wound classification IIC: 7 IID: 8 IIIC: 4 IIID: 9, all suffering from diabetes, and five were on dialysis. Treatment of a femoropopliteal lesion was performed during the same procedure in 6 of 28 patients (28.6%). Technical success was obtained in 25 out of 28 patients (89.3%), and procedural success was achieved in 23 of 28 patients (82.1%). No complications occurred at the pedal/tibial access. One minor complication at the femoral access was observed. The cure rate 6 months after the procedure was 57.1% (16/28 patients), and the 6-month survival rate was 96.4%. Three major amputations (10.7%) and four minor amputations (14.2%) were performed after revascularization procedures. Two patients were readmitted for vascular causes (7.1%). CONCLUSIONS Retrograde approach for revascularization of below-the-knee vessels in diabetic patients is safe and effective with high procedural and clinical success rates in the absence of significant complications. It should be considered when revascularization cannot be achieved with an antegrade transfemoral approach.
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Affiliation(s)
- Marco Nezzo
- Interventional Radiology Unit, Department of Biomedicine and Prevention, University of Rome Tor Vergata, Roma, Italy
| | - Marco Meloni
- Diabetic Foot Unit, Department of Systems Medicine, University of Rome Tor Vergata, Roma, Italy
| | - Alessandro Carini
- Interventional Radiology Unit, Department of Biomedicine and Prevention, University of Rome Tor Vergata, Roma, Italy
| | - Beatrice Carreri
- Interventional Radiology Unit, Department of Biomedicine and Prevention, University of Rome Tor Vergata, Roma, Italy
| | - Francesco Nicita
- Interventional Radiology Unit, Department of Biomedicine and Prevention, University of Rome Tor Vergata, Roma, Italy
| | - Francesco Garaci
- Diagnostic Imaging Unit, Department of Biomedicine and Prevention, University of Rome Tor Vergata, Roma, Italy
| | - Daniele Morosetti
- Interventional Radiology Unit, Department of Biomedicine and Prevention, University of Rome Tor Vergata, Roma, Italy
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McGuirl D, Giles KA. Retrograde Tibio-Pedal Access for Endovascular Interventions for Treating Peripheral Arterial Disease. Ann Vasc Surg 2024:S0890-5096(24)00154-7. [PMID: 38582196 DOI: 10.1016/j.avsg.2023.12.105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Accepted: 12/25/2023] [Indexed: 04/08/2024]
Abstract
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.
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Affiliation(s)
- Donald McGuirl
- Division of Vascular and Endovascular Surgery, Maine Medical Center, Portland, ME
| | - Kristina A Giles
- Division of Vascular and Endovascular Surgery, Maine Medical Center, Portland, ME.
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4
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Raskin D, Barash Y, Silverberg D, Halak M, Hater H, Khaitovich B. Retrograde tibial access for revascularization of chronic total occlusions in patients with chronic limb-threatening ischemia. Vascular 2023:17085381231192691. [PMID: 37553759 DOI: 10.1177/17085381231192691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/10/2023]
Abstract
PURPOSE To evaluate tibial single access in treatment of chronic total occlusions (CTO) in patients with ipsilateral chronic-limb ischemia (CLTI). MATERIALS AND METHODS In this retrospective study, data was collected on patients treated for ipsilateral CTO via a tibial artery access between March 2017 and March 2021. Fifty-nine limbs in 57 patients, (42 men, average age 73 years; range 47-96) were treated. Patient's symptoms were classified in accordance with the Rutherford category. The end points were freedom from major amputation and the need for reintervention up to 1 year of follow up. RESULTS Out of the 59 treated limbs, technical success was achieved in 57 (97%). The treated multilevel segments involved 5 common and 12 external iliac arteries, 23 common and 37 superficial femoral arteries, 23 femoropopliteal segments, 14 popliteal arteries, and 4 bypasses. Mean length of occlusion was 186 mm (range 7-670). Rutherford classification of the treated limbs was category 5 and 6 in 45 patients and category 4 in 14 patients. Three procedural complications occurred and were successfully treated during the same procedure. No immediate post-procedural complication was encountered. Median follow-up was 13 months (range 1-45.3). Reintervention was required in 9 limbs, after an average of 6 months. One year free from amputation rate was 91.2%. CONCLUSIONS Single access via the ipsilateral tibial artery can be a useful, effective, and safe approach for treating CTO in CLTI patients.
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Affiliation(s)
- Daniel Raskin
- Division of Diagnostic Imaging, Sheba Medical Center, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Yiftach Barash
- Division of Diagnostic Imaging, Sheba Medical Center, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Daniel Silverberg
- Department of Vascular Surgery, Sheba Medical Center, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Moshe Halak
- Department of Vascular Surgery, Sheba Medical Center, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Hatem Hater
- Department of Vascular Surgery, Sheba Medical Center, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Boris Khaitovich
- Division of Diagnostic Imaging, Sheba Medical Center, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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5
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Abstract
As the number of patients affected by peripheral arterial disease continues to increase, new technical approaches and devices have been developed to provide effective and durable treatment options that will lead to improved outcomes. While the mainstay of endovascular intervention remains mostly balloon-based, several innovative techniques and technologies are in development that may provide new solutions. This review highlights recent endovascular advancements in the management of chronic limb-threatening ischemia and additional adjunctive devices that are needed to improve lesion patency, reduce the need for reintervention, and lead to better patient-centered functional outcomes.
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Affiliation(s)
- Arash Fereydooni
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stanford University, Stanford, CA, USA
| | - Venita Chandra
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stanford University, Stanford, CA, USA; Stanford School of Medicine, 780 Welch Road, Palo Alto, CA 94304, USA.
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Abdelgawad MS, Wahba A, Elshafie AM, Abdelnaby M, Mowafy KA. Trans-pedal access for endovascular revascularization in complex infra-popliteal lesions in critically ischemic limb: A cohort study. Ann Med Surg (Lond) 2022; 81:104215. [PMID: 36147135 PMCID: PMC9486428 DOI: 10.1016/j.amsu.2022.104215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Revised: 07/14/2022] [Accepted: 07/20/2022] [Indexed: 11/30/2022] Open
Abstract
Background critical limb ischemia is one of the most challenging cases we face nowadays with high risk for amputation, retrograde trans-pedal angioplasty offers an alternative technique after failure of traditional ante-grade angioplasty. Patients and Methods 96 patients underwent trans-pedal or trans-tibial retrograde angioplasty after failure of the traditional ante-grade angioplasty with the aid of US, 21-gauge needle and 0.018 wire through sheath-less approach as a last chance for revascularization. Results clinical success or improvement in 77 cases (80.2%), and in other 19 cases (19.8%) there was no clinical success or improvement. The technical success was achieved in 81 cases with percentage of (84.4%), and not achieved in 15 cases (15.6%) only. Conclusions Retrograde Trans-pedal angioplasty is an efficient, safe, and practical procedure with a high technical success and a relatively minimal procedural adverse effect. retrograde trans-pedal angioplasty offers an alternative technique after failure of traditional ante-grade angioplasty. Retrograde Trans-pedal angioplasty is an efficient, safe, and practical procedure
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Mosarla RC, Armstrong E, Bitton-Faiwiszewski Y, Schneider PA, Secemsky EA. State-of-the-Art Endovascular Therapies for the Femoropopliteal Segment: Are We There Yet? JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2022; 1. [PMID: 36268042 PMCID: PMC9581461 DOI: 10.1016/j.jscai.2022.100439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Peripheral arterial disease is an increasingly prevalent condition with significant associated morbidity, mortality, and health care expenditure. Endovascular interventions are appropriate for most patients with either ongoing symptoms of intermittent claudication despite lifestyle and medical optimization or chronic limb-threatening ischemia. The femoropopliteal segment is the most common arterial culprit responsible for claudication and the most commonly revascularized segment. Endovascular approaches to revascularization of the femoropopliteal segment are advancing with an evolving landscape of techniques for arterial access, device-based therapies, vessel preparation, and intraprocedural imaging. These advances have been marked by debate and controversy, notably related to the safety of paclitaxel-based devices and necessity of atherectomy. In this review, we provide a critical overview of the current evidence, practice patterns, emerging evidence, and technological advances for endovascular intervention of the femoropopliteal arterial segment.
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Affiliation(s)
| | - Ehrin Armstrong
- Adventist Heart and Vascular Institute, St Helena, California
| | | | | | - Eric A. Secemsky
- Harvard Medical School, Boston, Massachusetts
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Corresponding author: (E.A. Secemsky)
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8
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Zenunaj G, Traina L, Acciarri P, Mucignat M, Scian S, Alesiani F, Serra R, Gasbarro V. Superficial femoral artery access for infrainguinal antegrade endovascular interventions in the hostile groin: A prospective randomized study. Ann Vasc Surg 2022; 86:127-134. [PMID: 35460853 DOI: 10.1016/j.avsg.2022.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 04/01/2022] [Accepted: 04/08/2022] [Indexed: 11/01/2022]
Abstract
INTRODUCTION In a hostile groin, it may be difficult to perform antegrade endovascular procedures at the lower extremities using the ipsilateral common femoral artery as vascular access; therefore, the use of the ipsilateral superficial femoral artery (SFA) could be a useful alternative. In this study, we evaluated the feasibility and safety of ultrasound-guided SFA puncture versus traditional SFA cutdown to achieve arterial access. METHODS This prospective observational randomized study examined patients with symptomatic peripheral arterial disease who required endovascular interventions at the lower extremities. A hostile groin was defined as high femoral bifurcation, obesity, and surgical scarring due to previous surgical interventions. A 6-Fr sheath (12 cm long; ULTIMUM™ EV INTRODUCER; Abbott, Plymouth, MN, USA) was used in all procedures. In the percutaneous group, the puncture was performed under ultrasound guidance and hemostasis was performed using a percutaneous closure device (PCD) (Angioseal Vip 6-Fr; Terumo Medical Corporation, Somerset, NJ, USA). The primary endpoints were technical success and perioperative complications. The secondary endpoints were the time required for the management of vascular access and the type of anesthesia administered. RESULTS Between 2020 and 2021, 107 patients who underwent antegrade revascularization were enrolled. SFA was achieved in 50 cases by the femoral cutdown technique (c-group) and in 57 cases by percutaneous ultrasound-guided puncture (p-group). In the c-group, the time from incision to sheath introduction and the time of suturing the artery and wound closure was 35 ± 8 min. In the p-group, the time from skin puncture and sheath placement plus that from the sheath removal and hole closure with the PCD was 6 ± 3 min. For the c-group versus p-group, the following variables were as follows: high bifurcation, 10 vs. 6 cases (=p 0.2); severe obesity, 33 vs. 40 cases (p 0.46); and previous surgical groin interventions, 7 vs. 9 cases (p 0.53), respectively. The technical success rates were 100% vs. 96.49% for the c-group vs. p-group, respectively (p 0.63). Two percutaneous puncture failures were managed using the cutdown technique. In the p-group, two post-procedural hematomas were recorded, with only one requiring surgical treatment and two with SFA occlusion to intravascular cap hemostatic dislocation, which were subjected to surgical revision. A total of three percutaneous procedures in the p-group required surgical revision versus none in the c-group (p =0.1). Within 3 months, complications consisted of 6 cases of surgical wound complications in the c-group versus none in the p-group (p 0.009). All procedures in the p-group versus 72% of patients in the c-group were managed with local anesthesia (p<0.0001). CONCLUSIONS The femoral cutdown technique seems to be safe and successful approach for achieving vascular access in cases of hostile groin. Ultrasound-guided puncture and PCD make SFA puncture a successful and safe alternative with an acceptable complications rate. Moreover, it reduces the time required to manage vascular access and can be performed mainly under local anesthesia.
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Affiliation(s)
- Gladiol Zenunaj
- Vascular Surgeon. Unit of Vascular and Endovascular Surgery, University Hospital of Ferrara, Italy.
| | - Luca Traina
- Vascular Surgeon. Unit of Vascular and Endovascular Surgery, University Hospital of Ferrara, Italy
| | - Pierfilippo Acciarri
- Vascular Surgeon. Unit of Vascular and Endovascular Surgery, University Hospital of Ferrara, Italy
| | - Marianna Mucignat
- Trainee in Vascular Surgery. School of Vascular Surgery, Department of Translational Medicine for Romagna, University of FerraraUniversity Hospital of Ferrara, Italy
| | - Sabrina Scian
- Trainee in Vascular Surgery. School of Vascular Surgery, Department of Translational Medicine for Romagna, University of FerraraUniversity Hospital of Ferrara, Italy
| | - Francesca Alesiani
- Trainee in Vascular Surgery. School of Vascular Surgery, Department of Translational Medicine for Romagna, University of FerraraUniversity Hospital of Ferrara, Italy
| | - Raffaele Serra
- Prof. Vascular Surgeon, Università Magna Graecia di Catanzaro, Italy
| | - Vincenzo Gasbarro
- Professor in Vascular Surgery Unit of Vascular and Endovascular Surgery, University Hospital of Ferrara, Italy
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Feldman ZM, Mohapatra A. Endovascular Management of Complex Tibial Lesions. Semin Vasc Surg 2022; 35:190-199. [DOI: 10.1053/j.semvascsurg.2022.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 04/12/2022] [Accepted: 04/13/2022] [Indexed: 11/11/2022]
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10
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Kim Y, Decarlo CS, Thangappan K, Zacharias N, Mohapatra A, Dua A. Distal Bypass Versus Infrageniculate Endovascular Intervention for Chronic Limb-Threatening Ischemia. Vasc Endovascular Surg 2022; 56:539-544. [PMID: 35356834 DOI: 10.1177/15385744221086347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Chronic limb-threatening ischemia (CLTI) carries a high risk of amputation and warrants urgent intervention. CLTI involving the infrageniculate vessels, in particular, carries a considerably higher risk of major limb amputation. Open surgical bypass is the historical gold standard for the treatment of tibial arterial disease; however, endovascular therapy provides an attractive alternative in this high-risk patient population. In this article, we review the existing literature regarding distal bypass and infrageniculate endovascular intervention in patients with CLTI.
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Affiliation(s)
- Young Kim
- Division of Vascular and Endovascular Surgery, Harvard Medical School, 2348Massachusetts General Hospital, Boston, MA. USA
| | - Charles S Decarlo
- Division of Vascular and Endovascular Surgery, Harvard Medical School, 2348Massachusetts General Hospital, Boston, MA. USA
| | - Karthik Thangappan
- Division of Vascular and Endovascular Surgery, Harvard Medical School, 2348Massachusetts General Hospital, Boston, MA. USA
| | - Nikolaos Zacharias
- Division of Vascular and Endovascular Surgery, Harvard Medical School, 2348Massachusetts General Hospital, Boston, MA. USA
| | - Abhisekh Mohapatra
- Division of Vascular and Endovascular Surgery, Harvard Medical School, 2348Massachusetts General Hospital, Boston, MA. USA
| | - Anahita Dua
- Division of Vascular and Endovascular Surgery, Harvard Medical School, 2348Massachusetts General Hospital, Boston, MA. USA
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11
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Singh N, Ding L, Magee GA, Shavelle DM. Contemporary treatment of below‐the‐knee peripheral arterial disease in patients with chronic limb threatening ischemia: Observations from the Vascular Quality Initiative. Catheter Cardiovasc Interv 2022; 99:1289-1299. [DOI: 10.1002/ccd.30063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 11/27/2021] [Accepted: 12/26/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Nikhil Singh
- Section of Cardiology, Department of Medicine University of Chicago Chicago Illinois USA
| | - Li Ding
- Department of Population and Public Health Sciences University of Southern California Keck School of Medicine Los Angeles California USA
| | - Gregory A. Magee
- Division of Vascular Surgery and Endovascular Therapy University of Southern California Keck School of Medicine Los Angeles California USA
| | - David M. Shavelle
- MemorialCare Heart and Vascular Institute Long Beach Memorial Medical Center Long Beach California USA
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12
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Abdelmonem M, Shahat M, Elashry M, Ali H. Retrograde tibiopedal access for chronic limb-threatening ischemia: A real-world experience report of 178 consecutive patients. INDIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2022. [DOI: 10.4103/ijves.ijves_123_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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13
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Onishi Y, Ohno T, Shimizu H, Hiramatsu H, Yokoyama A, Okamoto T, Nakamoto Y. Pediatric abdominal arterial intervention using a steerable microcatheter through an introducer with 4-F outer diameter: report of two cases. Radiol Case Rep 2021; 16:3326-3329. [PMID: 34484540 PMCID: PMC8403709 DOI: 10.1016/j.radcr.2021.07.095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 07/31/2021] [Indexed: 11/19/2022] Open
Abstract
In pediatric arteriography, vascular complications are more common than in adults; thus, the use of the smallest catheter to accomplish the objective of the procedure is recommended. We describe two pediatric cases in which abdominal arterial embolization and arteriography were performed with steerable microcatheters without conventional diagnostic catheters. Additionally, we used an introducer with an outer diameter of 4-F in a Mini Access Kit (Merit Medical, South Jordan, UT) as a vascular sheath to reduce sheath size. We believe that this technique may be feasible and safe for abdominal arterial interventions in children.
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Affiliation(s)
- Yasuyuki Onishi
- Department of Diagnostic Imaging and Nuclear Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
- Corresponding author. Yasuyuki Onishi.
| | - Tsuyoshi Ohno
- Department of Diagnostic Imaging and Nuclear Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Hironori Shimizu
- Department of Diagnostic Imaging and Nuclear Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Hidefumi Hiramatsu
- Department of Pediatrics, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Atsushi Yokoyama
- Department of Pediatrics, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Tatsuya Okamoto
- Department of Surgery, Kyoto University Graduatechool of Medicine, Kyoto, Japan
| | - Yuji Nakamoto
- Department of Diagnostic Imaging and Nuclear Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
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14
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[Innovations in the endovascular treatment of peripheral arterial disease]. GEFASSCHIRURGIE 2021; 26:347-358. [PMID: 34404965 PMCID: PMC8361829 DOI: 10.1007/s00772-021-00802-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 06/29/2021] [Indexed: 11/09/2022]
Abstract
Die Kooperation von Medizinern, Ingenieuren und anderen Naturwissenschaften bringt weiterhin effektive Produkte auf den Markt, die dazu geeignet sind, die Dominanz der endovaskulären Techniken im Bereich der peripheren arteriellen Verschlusskrankheit (pAVK) weiter auszubauen. Begleitend werden zunehmend bildgebende Verfahren weiterentwickelt oder neu entwickelt, die helfen können, die Strahlenbelastung für Patient und Anwender trotz wachsender Zahlen strahlenbasierter Therapieverfahren deutlich zu reduzieren. Mittlerweile haben wir ein Materialportfolio an der Hand, das es erlaubt, jede Gefäßregion endovaskulär zu behandeln. Auf der anderen Seite dürfte das endovaskuläre Leistungsgefüge nicht flächendeckend homogen gestaltet sein und die jeweilige Ergebnisqualität dann für die Chirurgie sprechen. In diesem Übersichtsartikel sollen neue Materialien und neuere Ergebnisse vorgestellt werden, die den Bereich der endovaskulären Behandlung der pAVK in allen Gefäßsegmenten mit beeinflussen dürften.
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Korleski H, DiChiacchio L, Araujo L, Hall MR. Multi-Level Lower Extremity Arterial Revascularization Via Retrograde Pedal Access Under Local Anesthesia in a Patient With Severe Cardiopulmonary Comorbidities: A Case Report. Vasc Endovascular Surg 2021; 56:49-52. [PMID: 34142625 DOI: 10.1177/15385744211026451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Chronic limb-threatening ischemia is a severe form of peripheral artery disease that leads to high rates of amputation and mortality if left untreated. Bypass surgery and antegrade endovascular revascularization through femoral artery access from either side are accepted as conventional treatment modalities for critical limb ischemia. The retrograde pedal access revascularization is an alternative treatment modality useful in specific clinical scenarios; however, these indications have not been well described in literature. This case report highlights the use of retrograde pedal access approach as primary treatment modality in a patient with an extensive comorbidities precluding general anesthesia nor supine positioning. CASE PRESENTATION The patient is a 60-year-old female with multiple severe cardiopulmonary comorbidities presenting with dry gangrene of the right great toe. Her comorbidities and inability to tolerate supine positioning precluded her from receiving open surgery, general anesthesia or monitored sedation, or percutaneous femoral access. Rather, the patient underwent ankle block and retrograde endovascular revascularization via dorsalis pedis artery access without post-operative complications. DISCUSSION The prevalence of comorbidities related to peripheral artery disease is increasing and with it the number of patients who are not optimal candidates for conventional treatment methods for critical limb ischemia. The retrograde pedal access revascularization as initial treatment modality offers these patients an alternative limb salvaging treatment option.
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Affiliation(s)
- Hee Korleski
- University of Maryland School of Medicine, Baltimore, MD, USA
| | | | - Luiz Araujo
- University of Maryland Medical Center, Baltimore, MD, USA
| | - Michael R Hall
- University of Maryland School of Medicine, Baltimore, MD, USA.,University of Maryland Medical Center, Baltimore, MD, USA
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Martin G, Covani M, Saab F, Mustapha J, Malina M, Patrone L. A systematic review of the ipsilateral retrograde approach to the treatment of femoropopliteal arterial lesions. J Vasc Surg 2021; 74:1394-1405.e4. [PMID: 34019987 DOI: 10.1016/j.jvs.2021.04.050] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 04/16/2021] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- Guy Martin
- West London Vascular and Interventional Centre, London North West University Healthcare NHS Trust, London, United Kingdom; Department of Surgery and Cancer, Imperial College London, London, United Kingdom.
| | - Marco Covani
- Faculty of Medicine, University of Messina, Messina, Italy
| | - Fadi Saab
- Advanced Cardiac & Vascular Centers for Amputation Prevention, Grand Rapids, Mich
| | - Jihad Mustapha
- Advanced Cardiac & Vascular Centers for Amputation Prevention, Grand Rapids, Mich
| | - Martin Malina
- West London Vascular and Interventional Centre, London North West University Healthcare NHS Trust, London, United Kingdom
| | - Lorenzo Patrone
- West London Vascular and Interventional Centre, London North West University Healthcare NHS Trust, London, United Kingdom
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Zhang H, Niu L, Zhang F, Luo X, Feng Y, Zhang C. Ultrasound-Guided Retrograde Infrapopliteal Artery Access for Recanalization of Complex Femoral-Popliteal Artery Occlusions. Ann Vasc Surg 2021; 76:357-362. [PMID: 33910048 DOI: 10.1016/j.avsg.2021.03.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 01/13/2021] [Accepted: 03/13/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND The aim of the study was to review the outcomes of femoral-popliteal artery (FPA) interventions using an ultrasound (US)-guided retrograde infrapopliteal artery access after the failure of an antegrade recanalization. METHODS From Jan 2016 to Jan 2019, 37 patients with chronic total occlusion (CTO) of the FPA underwent ultrasound (US)-guided retrograde infrapopliteal artery access after failure of an antegrade procedure. Treated limbs were classified as Rutherford class 5 or 6 (29.7%) and class 4 (62.2%). Data collected included success rate and time to access using US. Immediate in-hospital and follow-up outcomes were also documented. RESULTS US-guided retrograde infrapopliteal artery access was successful in 100% of the patients (anterior tibial = 11, posterior tibial = 19, Peroneal = 4, Dorsalis pedis = 3). Retrograde revascularization was achieved in all 37 patients (100%) using balloon angioplasty (17/37, 45.9%) and additional stent placement (20/37, 54.1%). Ankle-brachial index (ABI) measurements changed from 0.25 ± 0.1 preinterventionally to 0.75 ± 0.07 at 1 day postinterventionally (<0.001). Minor complications occurred in 2/37 patients (5.4%) including one bleeding and vasospasm at the posterior tibial artery, both of which were treated conservatively. No patient experienced access-related thrombosis, aneurysm, compartment syndrome or death. Thirty of 37 (81%) patients completed for at least 12 months of follow-up. None of the successful revascularized patients had major or minor amputations during the follow-up period. CONCLUSIONS US-guided retrograde infrapopliteal artery access is a safe and successful technique, which expands revascularization options after the failure of conventional endovascular antegrade approaches.
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Affiliation(s)
- Huan Zhang
- Department of Vascular Surgery, Beijing Shijitan Hospital, Capital Medical University, Haidian District, Beijing, People's Republic of China
| | - Luyuan Niu
- Department of Vascular Surgery, Beijing Shijitan Hospital, Capital Medical University, Haidian District, Beijing, People's Republic of China
| | - Fuxian Zhang
- Department of Vascular Surgery, Beijing Shijitan Hospital, Capital Medical University, Haidian District, Beijing, People's Republic of China.
| | - Xiaoyun Luo
- Department of Vascular Surgery, Beijing Shijitan Hospital, Capital Medical University, Haidian District, Beijing, People's Republic of China
| | - Yaping Feng
- Department of Vascular Surgery, Beijing Shijitan Hospital, Capital Medical University, Haidian District, Beijing, People's Republic of China
| | - Changming Zhang
- Department of Vascular Surgery, Beijing Shijitan Hospital, Capital Medical University, Haidian District, Beijing, People's Republic of China
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Rippel K, Ruhnke H, Jehs B, Decker J, Kroencke T, Scheurig-Muenkler C. Targeted tibio-peroneal re-entry during subintimal revascularization using the Outback® catheter. CVIR Endovasc 2021; 4:18. [PMID: 33507408 PMCID: PMC7843800 DOI: 10.1186/s42155-021-00206-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 01/06/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Re-entry devices are used regularly in subintimal recanalization of chronic occlusions of the iliac and femoro-popliteal arteries and significantly contribute to the high success rate of these interventions. However, the use in tibio-peroneal arteries has only been described in few cases so far. The present work is a retrospective evaluation of the Outback® re-entry device for gaining targeted true lumen access at the level of the tibio-peroneal arteries. METHODS From 9/2017 until 10/2020 the Outback® catheter was used in case of failed spontaneous re-entry at the level of the tibio-peroneal arteries in 14 patients either instead of the usual retrograde approach via a pedal/distal-crural access (n = 11) or in combination with it (n = 3). Baseline demographic and clinical data, morphologic characteristics of the occlusions, procedural succedss, as well as the Society of Vascular Surgery (SVS) runoff score before and after revascularization were documented. RESULTS All patients (median age: 78 years; range: 66-93) suffered from peripheral artery occlusive disease Rutherford stage 4 to 6 with a median lesion length of 12 cm (range: 7-35). Technical and procedural success was achieved in all 14 patients. The mean re-entry accuracy was 0.25 cm (range: 0-0.8). The SVS runoff score improved from a median of 14.5 (interquartile range IQR: 10.8-16.4) to 7 (IQR: 6.3-7) (p < 0.01). CONCLUSIONS The use of the Outback® catheter for targeted tibio-peroneal re-entry is associated with a high technical and procedural success rate and should be considered in case of otherwise failed ante- and retrograde recanalization.
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Affiliation(s)
- K Rippel
- Department of Diagnostic and Interventional Radiology, University hospital Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany.
| | - H Ruhnke
- Department of Diagnostic and Interventional Radiology, University hospital Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany
| | - B Jehs
- Department of Diagnostic and Interventional Radiology, University hospital Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany
| | - J Decker
- Department of Diagnostic and Interventional Radiology, University hospital Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany
| | - T Kroencke
- Department of Diagnostic and Interventional Radiology, University hospital Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany
| | - C Scheurig-Muenkler
- Department of Diagnostic and Interventional Radiology, University hospital Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany
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Giannopoulos S, Palena LM, Armstrong EJ. Technical Success and Complication Rates of Retrograde Arterial Access for Endovascular Therapy for Critical Limb Ischaemia: A Systematic Review and Meta-Analysis. Eur J Vasc Endovasc Surg 2020; 61:270-279. [PMID: 33358346 DOI: 10.1016/j.ejvs.2020.11.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 10/26/2020] [Accepted: 11/12/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Antegrade crossing techniques via transfemoral access are often challenging and may be associated with technical and clinical failure when treating patients with critical limb ischaemia (CLI). The objective of this study was to summarise all available literature regarding retrograde endovascular treatment of patients with CLI and to investigate the technical success and complication rate of retrograde access. METHODS A systematic literature search was performed in PubMed, Scopus, and Cochrane Central until May 2020. A meta-analysis of 31 observational studies (29 retrospective and two prospective; 26 and five studies with low and moderate risk of bias, respectively) was conducted with random effects modelling. The incidence of adverse events peri-procedurally and during follow up were calculated. RESULTS The 31 studies enrolled 1 910 patients who were treated endovascularly for femoropopliteal and/or infrapopliteal lesions causing CLI. Most of the patients had diabetes while more than half of the overall population had coronary artery disease and dyslipidaemia. All lesions were located in the infra-inguinal segment and most were chronic total occlusions (96%; 95% CI 85%-100%). Seven studies reported moderate or severe calcification in approximately half of the cases (45%; 95% CI 30%-60%). The overall technical success of the retrograde approach was 96% (18 studies; 95% CI 92%-100%). Perforation, flow limiting dissection, distal embolisation, and local haematoma at the retrograde access site were infrequent and observed in 2.1%, 0.6%, 0.1%, and 1.3% of the patients, respectively. The six month primary patency rate was 78% (five studies; 95% CI 46%-99%), the six month limb salvage rate was 77% (four studies; 95% CI 70%-84%). CONCLUSION The results indicated that the retrograde or bidirectional antegrade/retrograde approach is safe and effective and facilitates angioplasty when antegrade treatment fails. However, prospective studies with standardised wound care and surveillance protocols are needed to investigate retrograde techniques in patients with CLI who failed antegrade revascularisation, to improve long term limb salvage and survival.
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Affiliation(s)
- Stefanos Giannopoulos
- Division of Cardiology, Rocky Mountain Regional VA Medical Centre, University of Colorado, Denver, CO, USA
| | - Luis M Palena
- Endovascular Surgery Unit, Endovascular Interventions & Research, Foot & Ankle Clinic, Maria Cecilia Hospital, Cotignola, Italy
| | - Ehrin J Armstrong
- Division of Cardiology, Rocky Mountain Regional VA Medical Centre, University of Colorado, Denver, CO, USA.
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Retrograde Pedal Access via Occluded Arteries in Endovascular Treatment of Critical Limb Ischemia. J Vasc Interv Radiol 2020; 32:164-172. [PMID: 33248916 DOI: 10.1016/j.jvir.2020.08.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 08/14/2020] [Accepted: 08/30/2020] [Indexed: 01/20/2023] Open
Abstract
PURPOSE To evaluate the feasibility and technical outcomes of retrograde access via occluded pedal arteries in endovascular treatment of critical limb ischemia (CLI) when the conventional antegrade approach fails. MATERIALS AND METHODS One hundred fifty-one patients with CLI (age 69 y ± 10.5; 116 men) who were not surgical candidates and were treated via retrograde pedal access between January 2016 and January 2018 were evaluated retrospectively. Seventy patients in whom retrograde access was performed through occluded arteries constituted the occluded group, and 81 patients who were treated via retrograde access from patent arteries constituted the nonoccluded group. Pedal access success, lesion crossing success, angiographic success, overall technical success, and procedure-related complications were evaluated and compared between groups. RESULTS Pedal access success (74 of 78 vs 83 of 87 attempts; P = .873) and lesion crossing success (64 of 78 vs 77 of 87 lesions; P = .340) were comparable between subgroups. Angiographic success (54 of 78 vs 77 of 87 lesions; P = .012) and overall technical success (48 of 70 vs 72 of 81 patients; P = .004) rates were lower in the occluded group. Procedure-related complications were similar between groups (P = .096). CONCLUSIONS Retrograde pedal access from occluded pedal arteries is a feasible option when an antegrade approach fails in endovascular treatment of CLI. Although it has lower technical success, its use enables angiosome-directed therapy and has the potential to improve the outcomes of the procedure.
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21
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Min J, Park SW, Hwang JH, Kwon YW, Shin DH. Management of Complications during Below-the-Knee Endovascular Treatment: A Technical Note. Korean J Radiol 2020; 21:935-945. [PMID: 32677378 PMCID: PMC7369206 DOI: 10.3348/kjr.2019.0743] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Revised: 03/09/2020] [Accepted: 03/12/2020] [Indexed: 11/15/2022] Open
Abstract
We retrospectively reviewed the cases in which complications occurred during below-the-knee (BTK) endovascular treatments that were performed at our hospital from 2005 to 2014. Several interesting cases have been described herein. All the patients had diabetes and non-healing wounds on their feet and/or rest pain in their foot or leg, and therefore, endovascular treatment was performed for the BTK arteries of the affected lower extremity. The complications that occurred during the procedure were classified into six categories-vascular spasm, flow limiting dissection, perforation, broken guidewire, distal thromboembolism, and unusual puncture site bleeding. Each complication has its own solutions and management. We discuss these different classes of complications and describe how cases of each type were managed.
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Affiliation(s)
- JeeYoung Min
- Department of Radiology, Konkuk University Medical Center, Seoul, Korea
| | - Sang Woo Park
- Department of Radiology, Konkuk University Medical Center, Seoul, Korea.
| | - Jin Ho Hwang
- Department of Radiology, Konkuk University Medical Center, Seoul, Korea
| | - Yong Wonn Kwon
- Department of Radiology, Konkuk University Medical Center, Seoul, Korea
| | - Dong Hyeok Shin
- Department of Plastic and Reconstructive Surgery, Konkuk University Medical Center, Seoul, Korea
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22
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Leon LR, Green C, Labropoulos N, Pacanowski JP, Jhajj S, Pandit V. Distal Retrograde Access for Infrainguinal Arterial Chronic Total Occlusions: A Prospective, Single Center, Observational Study in the Office-Based Laboratory Setting. Vasc Endovascular Surg 2020; 55:143-151. [PMID: 33131462 DOI: 10.1177/1538574420968670] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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.
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Affiliation(s)
- Luis R Leon
- Department of Vascular and Endovascular Surgery at 12217University of Arizona, Tucson, AZ, USA.,Department of Vascular and Endovascular Surgery at Pima Vascular, Tucson, AZ, USA
| | - Courtney Green
- Department of Vascular and Endovascular Surgery at Pima Vascular, Tucson, AZ, USA
| | - Nicos Labropoulos
- Department of Vascular and Endovascular Surgery at Stony Brook, Long Island, New York, NY, USA
| | - John P Pacanowski
- Department of Vascular and Endovascular Surgery at 12217University of Arizona, Tucson, AZ, USA.,Department of Vascular and Endovascular Surgery at Pima Vascular, Tucson, AZ, USA
| | - Sandeep Jhajj
- Department of Vascular and Endovascular Surgery at 12217University of Arizona, Tucson, AZ, USA
| | - Viraj Pandit
- Department of Vascular and Endovascular Surgery at 12217University of Arizona, Tucson, AZ, USA
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Perry M, Callas PW, Alef MJ, Bertges DJ. Outcomes of Peripheral Vascular Interventions via Retrograde Pedal Access for Chronic Limb-Threatening Ischemia in a Multicenter Registry. J Endovasc Ther 2020; 27:205-210. [DOI: 10.1177/1526602820908056] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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.
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Affiliation(s)
- Mark Perry
- University of Vermont Medical Center, Burlington, VT, USA
| | - Peter W. Callas
- University of Vermont College of Medicine, Burlington, VT, USA
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Golamari RR, Finley JJ. Shockwave Intravascular Lithotripsy Via Exclusive Pedal Approach for the Treatment of Complicated Peripheral Arterial Disease. JACC Case Rep 2019; 1:583-587. [PMID: 34316884 PMCID: PMC8288826 DOI: 10.1016/j.jaccas.2019.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 09/11/2019] [Indexed: 12/03/2022]
Abstract
Shockwave intravascular lithotripsy for the treatment of peripheral arterial disease is routinely performed via femoral artery access. In patients with complex femoropopliteal disease, this traditional approach is not feasible. To address this situation, we used an exclusive pedal access approach along with other adjunctive treatments, resulting in a successful outcome. (Level of Difficulty: Advanced.)
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Affiliation(s)
- Reshma R. Golamari
- Department of Internal Medicine, Mercy Catholic Medical Center-Fitzgerald Campus, Darby, Pennsylvania
- Address for correspondence: Dr. Reshma R. Golamari, Mercy Catholic Medical Center, 1500 Lansdowne Avenue, Darby, Pennsylvania 19023.
| | - John J. Finley
- Department of Interventional Cardiology, Mercy Catholic Medical Center-Fitzgerald Campus, Darby, Pennsylvania
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Lu W, Wang L, Zhou W, Fu W. Augmented reality navigation to assist retrograde peroneal access for the endovascular treatment of critical limb ischemia. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2019; 5:518-520. [PMID: 31768482 PMCID: PMC6872763 DOI: 10.1016/j.jvscit.2019.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 06/08/2019] [Indexed: 11/25/2022]
Abstract
Retrograde access is an alternative approach to endovascular intervention for critical limb ischemia but may be challenging in patients with poor below-knee vessel runoff. Here, we introduce an innovative technique based on an augmented reality navigation system to gain successful retrograde access to the peroneal artery of an 84-year-old woman with critical limb ischemia. Our result showed that this innovative technique had the potential advantage of influencing target vessel access selection with lower contrast material volume and radiation exposure compared with the conventional approach. More in-depth study is required to investigate the safety and efficacy of augmented reality-assisted vascular interventions.
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Schmidt A, Bausback Y, Piorkowski M, Wittig T, Banning-Eichenseer U, Thiele H, Aldmour S, Branzan D, Scheinert D, Steiner S. Retrograde Tibioperoneal Access for Complex Infrainguinal Occlusions. JACC Cardiovasc Interv 2019; 12:1714-1726. [DOI: 10.1016/j.jcin.2019.06.048] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 05/08/2019] [Accepted: 06/04/2019] [Indexed: 10/26/2022]
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Sahajwani S, Orbay H, Santini R, Ucuzian A, Nagarsheth K. Transpedal Laser Atherectomy via a Communicating Branch to Treat Tibial Artery Chronic Total Occlusions. Am Surg 2019. [DOI: 10.1177/000313481908500902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Sunny Sahajwani
- Division of Vascular Surgery University of Maryland Medical Center Baltimore, Maryland
| | - Hakan Orbay
- Division of General Surgery University of Maryland Medical Center Baltimore, Maryland
| | - Rafeal Santini
- Division of Vascular Surgery University of Maryland Medical Center Baltimore, Maryland
| | - Areck Ucuzian
- Division of Vascular Surgery University of Maryland Medical Center Baltimore, Maryland
| | - Khanjan Nagarsheth
- Division of Vascular Surgery University of Maryland Medical Center Baltimore, Maryland
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28
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Analysis of the retrograde tibial artery approach in lower extremity revascularization in an office endovascular center. J Vasc Surg 2019; 70:157-165. [DOI: 10.1016/j.jvs.2018.10.114] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 10/22/2018] [Indexed: 11/30/2022]
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29
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Fırat A, İgüs B. Combined percutaneous direct puncture of occluded artery - antegrade intervention for recanalization of below the knee arteries. ACTA ACUST UNITED AC 2019; 25:320-327. [PMID: 31231068 DOI: 10.5152/dir.2019.18580] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE We aimed to assess the technical success of the combined percutaneous direct puncture of occluded artery - antegrade intervention technique, as well as the clinical effectiveness of treatment, on the basis of changes in the Rutherford classification. METHODS Between June 2015 and July 2018, 441 patients underwent endovascular recanalization due to lower limb peripheral arterial disease at our center. Of these, 18 patients (4%; 15 males, 3 females; mean age, 63.2 years) had failed antegrade recanalization and percutaneous retrograde access because of long segment occlusion, arterial rupture or dissection. Combined percutaneous direct puncture of occluded artery and antegrade approach was applied to these patients. Clinical follow-up examinations were performed at 1 month, 3 months, 6 months, and annually thereafter. RESULTS The mean follow-up period was 22.8±10.9 months. The mean procedure time was 93.6±28.2 min. Technical success was achieved in 14 patients (78%). Complete restoration of arterial flow in the punctured vessel could not be achieved in 4 patients (22%). Minor complications occurred in 4 of 18 procedures (22%). Amputation-free survival and limb salvage rates (83.3% and 100%, respectively) were the same for 12 and 24 months. CONCLUSION Technical success in lower limb peripheral arterial disease may be improved with the use of a combined percutaneous direct puncture of occluded artery - antegrade intervention, particularly for patients in whom other techniques are not a viable option.
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Affiliation(s)
- Ali Fırat
- Department of Radiology, İstanbul Başkent University School of Medicine, İstanbul, Turkey
| | - Behlül İgüs
- Department of Radiology, İstanbul Başkent University School of Medicine, İstanbul, Turkey
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30
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Biagioni RB, Brandão GD, Biagioni LC, Nasser F, Burihan MC, Ingrund JC. Endovascular treatment of TransAtlantic Inter-Society Consensus II D femoropopliteal lesions in patients with critical limb ischemia. J Vasc Surg 2019; 69:1510-1518. [DOI: 10.1016/j.jvs.2018.08.176] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 08/13/2018] [Indexed: 10/27/2022]
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31
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Armstrong EJ, Shishehbor MH. Commentary: Contemporary Outcomes of Endovascular Interventions for Peripheral Artery Disease: The LIBERTY to Determine Optimal Treatment Strategies. J Endovasc Ther 2019; 26:155-157. [DOI: 10.1177/1526602819833064] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Ehrin J. Armstrong
- Rocky Mountain Regional VA Medical Center, Aurora, CO, USA
- Division of Cardiology, University of Colorado, Aurora, CO, USA
| | - Mehdi H. Shishehbor
- Case Western Reserve University School of Medicine and Harrington Heart and Vascular Institute, University Hospitals, Cleveland, OH, USA
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Firat A, Igus B. Endovascular Recanalization of Thromboangiitis Obliterans (Buerger’s Disease) in Twenty-Eight Consecutive Patients and Combined Antegrade–Retrograde Intervention in Eight Patients. Cardiovasc Intervent Radiol 2019; 42:820-828. [DOI: 10.1007/s00270-019-02193-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 02/21/2019] [Indexed: 12/24/2022]
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Stern JR, Cafasso DE, Connolly PH, Ellozy SH, Schneider DB, Meltzer AJ. Safety and Effectiveness of Retrograde Arterial Access for Endovascular Treatment of Critical Limb Ischemia. Ann Vasc Surg 2019; 55:131-137. [DOI: 10.1016/j.avsg.2018.08.072] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 05/09/2018] [Accepted: 08/06/2018] [Indexed: 12/19/2022]
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Armstrong EJ, Alam S, Henao S, Lee AC, DeRubertis BG, Montero-Baker M, Mena C, Cua B, Palena LM, Kovach R, Chandra V, AlMahameed A, Walker CM. Multidisciplinary Care for Critical Limb Ischemia: Current Gaps and Opportunities for Improvement. J Endovasc Ther 2019; 26:199-212. [DOI: 10.1177/1526602819826593] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Critical limb ischemia (CLI), defined as ischemic rest pain or nonhealing ulceration due to arterial insufficiency, represents the most severe and limb-threatening manifestation of peripheral artery disease. A major challenge in the optimal treatment of CLI is that multiple specialties participate in the care of this complex patient population. As a result, the care of patients with CLI is often fragmented, and multidisciplinary societal guidelines have not focused specifically on the care of patients with CLI. Furthermore, multidisciplinary care has the potential to improve patient outcomes, as no single medical specialty addresses all the facets of care necessary to reduce cardiovascular and limb-related morbidity in this complex patient population. This review identifies current gaps in the multidisciplinary care of patients with CLI, with a goal toward increasing disease recognition and timely referral, defining important components of CLI treatment teams, establishing options for revascularization strategies, and identifying best practices for wound care post-revascularization.
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Affiliation(s)
- Ehrin J. Armstrong
- Division of Cardiology, University of Colorado and Rocky Mountain Regional VA Medical Center, Denver, CO, USA
| | - Syed Alam
- Advanced Cardiac and Vascular Centers, Grand Rapids, MI, USA
| | - Steve Henao
- Division of Vascular Surgery, New Mexico Heart Institute, Albuquerque, NM, USA
| | - Arthur C. Lee
- The Cardiac and Vascular Institute, Gainesville, FL, USA
| | - Brian G. DeRubertis
- Division of Vascular Surgery, University of California, Los Angeles, CA, USA
| | | | - Carlos Mena
- Division of Cardiology, Yale University, New Haven, CT, USA
| | | | | | | | - Venita Chandra
- Division of Vascular Surgery, Stanford University, Stanford, CA, USA
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Taha AG, Abou Ali AN, Al-Khoury G, Singh MJ, Makaroun MS, Avgerinos ED, Chaer RA. Outcomes of infrageniculate retrograde versus transfemoral access for endovascular intervention for chronic lower extremity ischemia. J Vasc Surg 2018; 68:1088-1095. [DOI: 10.1016/j.jvs.2018.01.028] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2017] [Accepted: 01/01/2018] [Indexed: 11/27/2022]
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Abstract
Retrograde pedal access is a technique utilized with increasing frequency by many interventionists to address patients with advanced multilevel peripheral artery disease and significant comorbidities. This approach to revascularization is being used both in patients who fail traditional antegrade access and in some patients thought to be poor candidates for antegrade approach. However, the lack of randomized controlled trial data, or long-term results, coupled with the associated potential risks including dissection, spasm, and thrombosis have rendered retrograde pedal access a controversial topic. This article details the pros and cons associated with the debate surrounding retrograde pedal access and highlights the current literature and remaining questions regarding outcomes of this technique.
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Affiliation(s)
- Anahita Dua
- 1 Division of Vascular Surgery, Department of Surgery, Stanford Hospitals and Clinics, Palo Alto, CA, USA
| | - Venita Chandra
- 1 Division of Vascular Surgery, Department of Surgery, Stanford Hospitals and Clinics, Palo Alto, CA, USA
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Vance AZ, Leung DA, Clark TW. Tips for pedal access: technical evolution and review. THE JOURNAL OF CARDIOVASCULAR SURGERY 2018; 59:685-691. [PMID: 29905414 DOI: 10.23736/s0021-9509.18.10627-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Pedal access has become an indispensable technique for endovascular therapy of complex lower extremity peripheral vascular disease. From an option as a single access in a patient lacking traditional access approaches to a critical maneuver in combined antegrade-retrograde approaches during the treatment of complex chronic total occlusions, pedal access is an essential tool for any endovascular physician treating peripheral arterial disease. Anticipatory planning is critical in the successful utilization of pedal access. The appropriate tibiopedal vessel should be chosen and combined with the ideal access technique. Knowledge of the current medical devices available for pedal access and post-procedural hemostasis is key and can ease the learning curve. We present the evolution of pedal access with a review of the literature and technical tips to incorporate into everyday practice.
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Affiliation(s)
- Ansar Z Vance
- Division of Interventional Radiology, Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA -
| | - Daniel A Leung
- Department of Vascular and Interventional Radiology, Christiana Care Health System, Newark, DE, USA
| | - Timothy W Clark
- Division of Interventional Radiology, Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Kaushal A, Roche-Nagle G, Tan KT, Liao E, Eisenberg N, Oreopoulos GD, Rajan DK. Outcomes at a single center after subintimal arterial flossing with antegrade-retrograde intervention for critical limb ischemia. J Vasc Surg 2018; 67:1448-1454. [DOI: 10.1016/j.jvs.2017.08.091] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Accepted: 08/30/2017] [Indexed: 12/01/2022]
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Ryer EJ, Elmore JR. Commentary: Below-the-Knee Retrograde Access for Peripheral Interventions: A Valuable Technique for the Limb Salvage Toolbox. J Endovasc Ther 2018; 25:353-354. [PMID: 29642735 DOI: 10.1177/1526602818766854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Evan J Ryer
- 1 Department of Vascular and Endovascular Surgery, Vascular Institute, Geisinger Medical Center, Danville, PA, USA
| | - James R Elmore
- 1 Department of Vascular and Endovascular Surgery, Vascular Institute, Geisinger Medical Center, Danville, PA, USA
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Welling RHA, Bakker OJ, Scheinert D, Moll FL, Hazenberg CE, Mustapha JA, de Borst GJ, Schmidt A. Below-the-Knee Retrograde Access for Peripheral Interventions: A Systematic Review. J Endovasc Ther 2018; 25:345-352. [PMID: 29575992 DOI: 10.1177/1526602818765248] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE To investigate the hypothesis that interventions involving retrograde below-the-knee (BTK) vessel punctures have an acceptably low complication rate and high procedural success. METHODS A systematic review was performed of the MEDLINE and Scopus databases for articles describing the results of BTK retrograde access for peripheral interventions. Outcome measures were access success, procedure success, and complications. A predefined subgroup analysis was performed of prospective studies to reduce the influence of possible reporting bias on outcomes. RESULTS Nineteen articles, including 3 prospective studies, were selected, including a total of 1905 interventions in 1395 patients (mean age 69.5 years; 918 men). The BTK vessels were punctured in 1168 (61.3%) of these interventions. Access was successful in 94.0% of BTK attempts, 86.0% of all lesions were successfully crossed using a retrograde access, and 84.0% of interventions achieved technical success. Forty-eight (4.1%) distal access site complications were reported. Vessel perforations were seen in 13 (1.1%) interventions, vasospasm in 5 (0.4%), and acute distal occlusions in 5 (0.4%). Predefined subgroup analysis of prospective studies showed similar results (p=0.24). CONCLUSION A retrograde approach to facilitate peripheral endovascular interventions is a safe and successful technique and should be considered when an antegrade approach is not possible or fails to cross the lesion. Because of missing data on long-term outcomes and methodological shortcomings, real world data of retrograde access in nonexpert centers remains necessary before this technique can be advised to all interventionists dealing with peripheral artery disease.
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Affiliation(s)
- Rutger H A Welling
- 1 Department of Vascular & Endovascular Surgery, University Medical Center Utrecht, the Netherlands
| | - Olaf J Bakker
- 2 Department of Vascular & Endovascular Surgery, Franciscus & Vlietland Hospital, Rotterdam, the Netherlands
| | - Dierk Scheinert
- 3 Department of Interventional Angiology, University Hospital Leipzig, Germany
| | - Frans L Moll
- 1 Department of Vascular & Endovascular Surgery, University Medical Center Utrecht, the Netherlands
| | - Constantijn E Hazenberg
- 1 Department of Vascular & Endovascular Surgery, University Medical Center Utrecht, the Netherlands
| | - Jihad A Mustapha
- 4 Department of Cardiovascular Medicine, Metro Health University of Michigan Health, Wyoming, MI, USA
| | - Gert J de Borst
- 1 Department of Vascular & Endovascular Surgery, University Medical Center Utrecht, the Netherlands
| | - Andrej Schmidt
- 3 Department of Interventional Angiology, University Hospital Leipzig, Germany
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Retrograde Tibiopedal Access as a Bail-Out Procedure for Endovascular Intervention Complications. Case Rep Vasc Med 2016; 2016:7519748. [PMID: 27803837 PMCID: PMC5075623 DOI: 10.1155/2016/7519748] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Revised: 09/05/2016] [Accepted: 09/20/2016] [Indexed: 11/18/2022] Open
Abstract
Introduction. Retrograde pedal access has been well described in the literature as a secondary approach for limb salvage in critical limb ischemia (CLI) patients. In this manuscript we are presenting a case where retrograde tibiopedal access has been used as a bail-out procedure for the management of superficial femoral artery (SFA) intervention complications. Procedure/Technique. After development of a perforation while trying to cross the totally occluded mid SFA using the conventional CFA access, we were able to cross the mid SFA lesion after accessing the posterior tibial artery in a retrograde fashion and delivered a self-expanding stent which created a flap that sealed the perforation without the need for covered stent. Conclusion. Retrograde tibiopedal access is a safe and effective approach for delivery of stents from the distal approach and so can be used as a bail-out technique for SFA perforation.
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