Retrograde distal access versus femoral access for below the knee angioplasty

BACKGROUND

The prevalence of peripheral artery disease (PAD) in the general population is about 12% to 14% and it increases with age. PAD increased from 164 million people in 2000 to 202 million people in 2010. More than two-thirds of people with PAD are based in low- or middle-income countries. Critical limb ischaemia (CLI) occurs in 1% to 2% of people with intermittent claudication over five years. One third of people with CLI have isolated below the knee (BTK) lesions. CLI and isolated BTK lesions are associated with a higher incidence of limb loss when compared with people with multilevel arterial disease. Endovascular procedures such as angioplasty (with or without stenting) are widely used to treat isolated BTK lesions, aiming to improve blood flow and limb salvage. The technical success of any angioplasty procedure depends on the ability to cross the target lesion. Failed attempts are underestimated in the literature and failures in the real world appear to be higher than reported. People with isolated BTK lesions undergoing angioplasty by conventional femoral access present a high failure rate to cross these lesions. Retrograde distal access may provide some advantages that can lead to successful crossing of the target lesion.

OBJECTIVES

To evaluate the benefits and harms of retrograde distal access versus conventional femoral access for people undergoing below the knee angioplasty.

SEARCH METHODS

The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase and CINAHL databases, and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 26 September 2022.

SELECTION CRITERIA

We planned to include randomised or quasi-randomised controlled trials comparing people undergoing retrograde distal access versus people undergoing conventional femoral access (ipsilateral antegrade or contralateral retrograde) for BTK angioplasty.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed identified studies for potential inclusion in the review. We used standard methodological procedures in accordance with the Cochrane Handbook for Systematic Review of Interventions. Our primary outcomes were technical success of angioplasty procedure and major procedural complications. Our secondary outcomes were mortality rate, amputation-free survival, primary patency, minor procedural complications and wound healing. We planned to use GRADE to assess the certainty of the evidence for each outcome.

MAIN RESULTS

We identified no randomised or quasi-randomised controlled trials that met the inclusion criteria.

AUTHORS' CONCLUSIONS

We identified no randomised or quasi-randomised controlled trials that compared retrograde distal access versus femoral access for BTK angioplasty. High-quality studies that compare retrograde distal access versus conventional femoral access for BTK angioplasty are needed.

Direct puncture versus contralateral femoral artery approach for catheter-directed thrombolysis of occluded infra-inguinal arterial bypass grafts

AIM

To compare the safety, effectiveness, and clinical outcome of percutaneous direct puncture approach versus contralateral femoral native vessel approach for catheter-directed thrombolysis of occluded infra-inguinal bypass grafts.

MATERIALS AND METHODS

A retrospective analysis was performed comprising a cohort of patients who underwent catheter-directed thrombolysis procedures of occluded infra-inguinal bypass grafts between January 2013 and January 2022, with a follow-up period until June 2022. This included 55 procedures via the native vessel approach and 18 procedures via the direct puncture approach. Primary outcomes were technical success and procedural safety; secondary outcomes included re-intervention rate, limb salvage, and mortality as assessed by log-rank testing and Kaplan-Meier curves.

RESULTS

There were no differences between the two groups with regard to patient demographics, except for the number of previous vascular procedures (n=6.83 ± 3.07 direct approach versus n=4.96 ± 2.79 native vessel approach, p=0.025). Thrombolysis was comparably successful in both groups (n=13/18; 72% direct approach versus n=42/55; 76%, p=0.723). There were no differences in the duration of thrombolysis administration. The rate of adverse events was slightly lower in the direct approach group, but without significance (p=0.092). There were no adverse events related to the puncture site in the direct approach group. No differences were found between the time-to-event values for re-occlusion, re-intervention, amputation, or mortality respectively (p=0.662; p=0.520; p=0.816; p=0.462).

CONCLUSION

The direct puncture approach seems to be a safe and efficient approach for catheter-directed thrombolysis procedures in infra-inguinal occluded bypass grafts, with clinical outcomes comparable to the native vessel approach.

The Utility of Ultrasound Guidance to Improve the Safety of Closure of Antegrade Common Femoral Artery Access after Lower Limb Revascularization

This study aimed to investigate the feasibility of ultrasound (US)-guidance in reducing adverse event (AE) rates when using Angioseal device during antegrade lower limb angioplasty via common femoral artery access. From December 2016 to November 2022, 1,322 patients were identified, including 1,131 (85.6%) patients who underwent US-guided closure and 191 (14.4%) who underwent non-US-guided closure. Moderate AEs were encountered in 10 (5.2%) patients in the non-US-guided closure group compared to 38 (3.4%) patients in the US-guided closure group (P = .208). Severe AEs were encountered in 4 (2.1%) patients in the non-US-guided closure group compared to 3 (0.3%) patients in the US-guided closure group (P = .010). Overall AEs occurred in 14 (7.3%) patients in the non-US-guided closure group compared to 41 (3.6%) patients in the US-guided closure group (P = .029). Binary logistic regression showed that only non-US guidance was an independent risk factor for the occurrence of severe AEs (P = .008).

Sheathless use of Supera stent minimizes access complications in antegrade femoral puncture: Technical note with case series

Antegrade femoral puncture (AFP) is the preferred strategy to treat lower limb obstructive disease. However, the presence of vascular calcification may be associated with procedure related adverse events, impairing endovascular device strategies. We describe a case series of superficial femoral and popliteal artery treatments by Supera stent implantation using a simple technique to significantly minimize the dimension of the antegrade femoral puncture from 6 to 4 French (Fr). All antegrade femoral punctures, crossing femoro-popliteal lesion and predilation were made with 4 Fr introducer. After preparation the Supera stent was navigated in sheathless fashion via 0.018-inch guidewire. Postdilation and final control were made replacing the 4 Fr introducer via the same guidewire. A good final result was achieved. Patients were discharged early without any complications. This minimally invasive technique in cases of infrainguinal peripheral artery disease could be feasible and effective for minimizing the risk of complications in patients with critical limb ischemia.

Choosing the appropriate catheter and wire in peripheral intervention

Endovascular treatment is becoming more common in managing patients with peripheral arterial disease. A carefully planned procedure is crucial for the outcome of the procedure. Several steps are necessary when performing endovascular procedures, including preplanning with vascular imaging using computed tomography angiography (CTA) or magnetic resonance angiography (MRA), choosing the right access and technique, and using the right devices (guidewires, sheaths, catheters). The length, diameter, stiffness, coating, and tip shape of the guidewire should be adjusted according to the initial information and preparation. A sheath is not always necessary but can be beneficial when several catheter changes are planned. There are three types of angiographic catheter (flush, exchange, and selective), each of which should be considered and used wisely according to its function. The guidewire, sheath, and catheter choices will follow from the initial information gathered, the access and technique chosen, and the availability of the devices.

The role of atherectomy in BTK lesions. A systematic review

INTRODUCTION

To evaluate the current role of atherectomy techniques (ATH) in treatment of peripheral arterial disease (PAD) at below the knee (BTK) arteries.

EVIDENCE ACQUISITION

The PubMed and Embase were searched (last search on 11 September 2021) for studies reporting on the early and mid-term outcomes of ATH in BTK vessels. Analysis included the data from six studies, with a total of 1062 PAD patients treated with various ATH techniques. We compared them the ATH outcomes with the contemporaneous outcomes of plain balloon angioplasty alone or with bailout stenting. Early safety and efficacy were accessed with perioperative and 30-day technical success rate, which included the primary patency of the treated BTK arterial segment. Evaluation of clinical performance was based on target limb revascularization (TLR) and on major limb adverse events (MALEs) rates.

EVIDENCE SYNTHESIS

The current body of literature mainly includes retrospective observational studies, and the level of derived evidence is low. The mean perioperative and 30-day technical success rate was 87.3%. The mean reported TLR and MALEs rates at 12 months were 6.6% and 4.7% respectively. The relevant rates in studies reporting at 24 months were 24.3% and 31.7% while in studies reporting at 36 months the rates were 37.0% and 23.0% respectively.

CONCLUSIONS

Based in low-quality evidence, it seems that ATH in BTK vessels has a high safety, high efficacy profile and durable outcomes at 12 months. In the midterm, the clinical success of ATH is compromised by increased TLR and MALEs rates. Comparison of ATH with other endovascular techniques in BTK treatment of PAD shows a slight lead of ATH at 1-year and equivalent clinical performance in the mid-term. Overall, ATH has a significant and potentially predominant role in treatment of BTK vessels.

Comparison between antegrade common femoral artery access and superficial femoral artery access in infrainguinal endovascular interventions

BACKGROUND

Antegrade access for infrainguinal endovascular intervention can be achieved through the common femoral artery (CFA) or superficial femoral artery (SFA). A few studies with small sample sizes have shown similar efficacy and safety for antegrade puncture of the CFA and SFA. In the present study, we analyzed the feasibility of SFA access and the occurrence of complications between SFA and CFA ipsilateral access in a broader cohort.

METHODS

In the present retrospective study, we analyzed data from 462 patients with peripheral arterial disease (PAD) who had undergone peripheral angioplasty from 2009 to 2016. The inclusion criteria were PAD at Rutherford stage 3 to 6 and use of an endovascular approach. Patients with coagulation disorders, those receiving anticoagulant therapy, cases with deployment of closure devices, cases with more than one access on the same limb, and patients with inadequate bed rest after the procedure were excluded. A systematic analysis of all patients' electronic medical records was performed to evaluate the demographic aspects and technical success and identify the possible complications associated with CFA and SFA access.

RESULTS

Of the 462 patients, 290 had undergone SFA puncture and 172, CFA puncture. The demographic evaluation of both groups revealed no differences between the two groups, except that more patients with diabetes were in the CFA group and more patients with dyslipidemia and an advanced clinical presentation were in the SFA group. First puncture access was successful in 99.7% of the SFA group and 96.5% of the CFA group (P = .01). The hematoma rate in the SFA and CFA groups was 20.3% and 11%, respectively (P = .01). The incidence of major bleeding and clinically relevant nonmajor bleeding was not significantly different between the two groups (P = .215). Only three patients had developed a pseudoaneurysm, two of whom were in the SFA group. Female sex (odds ratio [OR], 2.572; 95% confidence interval [CI], 1.520-4.354; P < .001] and older age (OR, 1.034; 95% CI, 1.009-1.059; P = .007) were associated with an increased hematoma rate.

CONCLUSIONS

SFA access was associated with a higher overall rate of hematoma compared with CFA access. However, no significant difference was found in the incidence of major bleeding between the two access sites. Planned SFA access should be considered as an alternative to CFA access.

Retrograde distal access versus femoral access for below the knee angioplasty

This is a protocol for a Cochrane Review (intervention). The objectives are as follows:

To compare the effectiveness and safety of retrograde distal access versus conventional femoral access for people undergoing below the knee angioplasty.

Antegrade common femoral artery closure device use is associated with decreased complications

OBJECTIVE

Antegrade femoral artery access is often used for ipsilateral infrainguinal peripheral vascular intervention. However, the use of closure devices (CD) for antegrade access (AA) is still considered outside the instructions for use for most devices. We hypothesized that CD use for antegrade femoral access would not be associated with an increased odds of access site complications.

METHODS

The Vascular Quality Initiative was queried from 2010 to 2019 for infrainguinal peripheral vascular interventions performed via femoral AA. Patients who had a cutdown or multiple access sites were excluded. Cases were then stratified into whether a CD was used or not. Hierarchical multivariable logistic regressions controlling for hospital-level variation were used to examine the independent association between CD use and access site complications. A sensitivity analysis using coarsened exact matching was performed using factors different between treatment groups to reduce imbalance between the groups.

RESULTS

Overall, 11,562 cases were identified and 5693 (49.2%) used a CD. Patients treated with a CD were less likely to be white (74.1% vs 75.2%), have coronary artery disease (29.7% vs 33.4%), use aspirin (68.7% vs 72.4%), and have heparin reversal with protamine (15.5% vs 25.6%; all P < .05). CD patients were more likely to be obese (31.6% vs 27.0%), have an elective operation (82.6% vs 80.1%), ultrasound-guided access (75.5% vs 60.6%), and a larger access sheath (6.0 ± 1.0 F vs 5.5 ± 1.0 F; P < .05 for all). CD cases were less likely to develop any access site hematoma (2.55% vs 3.53%; P < .01) or a hematoma requiring reintervention (0.63% vs 1.26%; P < .01) and had no difference in access site stenosis or occlusion (0.30% vs 0.22%; P = .47) compared with no CD. On multivariable analysis, CD cases had significantly decreased odds of developing any access site hematoma (odds ratio, 0.75; 95% confidence interval, 0.59-0.95) and a hematoma requiring intervention (odds ratio, 0.56; 95% confidence interval, 0.38-0.81). A sensitivity analysis after coarsened exact matching confirmed these findings.

CONCLUSIONS

In this nationally representative sample, CD use for AA was associated with a lower odds of hematoma in selected patients. Extending the instructions for use indications for CDs to include femoral AA may decrease the incidence of access site complications, patient exposure to reintervention, and costs to the health care system.

Combined percutaneous direct puncture of occluded artery - antegrade intervention for recanalization of below the knee arteries

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.