Extreme Below-the-Knee Interventions: Retrograde Transmetatarsal or Transplantar Arch Access for Foot Salvage in Challenging Cases of Critical Limb Ischemia

Below-the-Ankle Antegrade Teleferic Technique: New Approach for Below-the-Ankle Revascularization in Challenging Cases of Chronic Limb-Threatening Ischemia

PURPOSE

To describe a novel bailout technique to approach below-the-ankle (BTA) chronic total occlusions or plantar-arch severe disease where the balloon/catheter is unable to follow the crossing guidewire and no other described recanalization approach is feasible.

TECHNIQUE

When facing a complex BTA revascularization, if the guidewire crosses but the balloon cannot progress due to a lack of pushability, an antegrade puncture of the infrapopliteal vessel where the tip of the guidewire lays is performed. The guidewire is then carefully navigated through this distal BTA vessel into the needle to achieve its rendezvous and externalization. A low-profile balloon is inserted through the femoral access and advanced till the non-crossable point of the BTA vessels. A torque device is then attached to the proximal hub of the balloon, and the through-and-through guidewire is subsequently pulled from the new distal access, allowing the balloon to be dragged across the lesion together with the wire.

CONCLUSION

The below-the-ankle antegrade teleferic (BAT) technique may be considered for highly complex BTA revascularization procedures where the wire crosses the lesion, but no other device can be tracked over it.

CLINICAL IMPACT

The clinical impact of this article lies in the description of a bailout technique for BTA revascularization where the guidewire crosses, but no device can be advanced. This technique can be helpful in scenarios where failure to achieve success could result in limb loss. The BAT technique provides a solution in extremely challenging cases, enhancing technical success, improving outcomes and potentially preserving the limbs of patients who would otherwise face amputation, if not revascularized.The video shows the BAT technique performed with a support catheter under fluoroscopy: antegrate puncture of the DP, advancement of the support catheter over the wire, rendezvous of the guidewire in the catheter and subsequent externalization of the wire.

Intraoperative Pedal Pressure Changes Offers Another Quantitative Assessment for Revascularization

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.

Below-the-Knee Endovascular Revascularization: A Position Statement

Patients with chronic limb-threatening ischemia, the terminal stage of peripheral artery disease, are frequently afflicted by below-the-knee disease. Although all patients should receive guideline-directed medical therapy, restoration of inline flow is oftentimes necessary to avoid limb loss. Proper patient selection and proficiency in endovascular techniques for below-the-knee revascularization are intended to prevent major amputation and promote wound healing. This review, a consensus among an international panel of experienced operators, provides guidance on these challenges from an endovascular perspective and offers techniques to navigate this complex disease process.

Successful extreme foot revascularization with plaque cracking (percutaneous direct needle puncture of calcified plaque) technique of medial tarsal artery

The percutaneous direct needle puncture of calcified plaque technique is a valuable method to allow for extreme revascularization of occluded below-the-ankle vessels. We report the case of an antegrade recanalization technique from the peroneal artery to medial plantar artery to achieve external "cracking" of a calcified plaque of the medial tarsal artery.

Inframalleolar thrice distal puncture in a single endovascular treatment session for successful revascularization

BACKGROUND

Most patients with chronic limb-threatening ischemia (CLTI) have infrapopliteal arterial disease, which are often challenging to treat. In endovascular treatment (EVT) for these complex lesions, establishing retrograde access is an essential option not only for guidewire crossing but also for device delivery. However, no EVT case has yet been reported requiring inframalleolar thrice distal puncture in a single EVT session so far.

CASE PRESENTATION

A 60-year-old CLTI patient with grade 3 Wound, Ischemia and foot Infection (WIfI) classification underwent EVT for occluded dorsal artery and posterior tibial artery. First, we conducted successful balloon angioplasty of the posterior tibial artery by establishing a retrograde approach via the lateral plantar artery. To treat the occlusion of the dorsal artery, we punctured the first dorsal metatarsal artery, and retrogradely advanced a guidewire to the dorsal artery occlusion; however, the microcatheter could not follow the guidewire. Therefore, we punctured the occluded distal anterior tibial artery and introduced the retrograde guidewire into the puncture needle. After guidewire externalization, we pulled up the retrograde microcatheter into the occlusion of dorsal artery using the "balloon deployment using forcible manner" technique. Thereafter, we were able to advance the antegrade guidewire into the retrograde microcatheter. After guidewire externalization, an antegrade balloon catheter was delivered and inflated for the purpose of dorsal artery dilation and hemostasis at the "needle rendezvous" point. Consecutively, balloon dilation was performed for puncture site hemostasis of the first dorsal metatarsal artery and complete hemostasis was achieved. Finally, we confirmed good vascular patency and favorable blood flow. After revascularization, transmetatarsal amputation was performed and the wound healed favorably.

CONCLUSIONS

We can markedly increase the success rate of revascularization by effectively utilizing the retrograde approach in EVT for complex chronic total occlusions in infrapopliteal arterial diseases.

Superficial Femoral Artery Remote Endarterectomy: A Systematic Review And Meta-analysis

BACKGROUND

Objective: Remote Superficial Femoral Artery Endarterectomy (RSFAE) is a hybrid procedure with low risk for peri-operative complications and promising patency rates over time. The aim of this study was to summarize current literature and to determine the role of RSFAE in limb salvage with regards to technical success, limitations, patency rates and long-term outcomes.

METHODS

This systematic review and meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

Overall 19 studies were identified, comprising 1,200 patients with extensive femoropopliteal disease among whom 40% presented with chronic limb threatening ischemia. The average technical success rate was 96%, with a 7% rate for peri-operative distal embolization and 13% rate for SFA perforation. The primary patency was 64% and 56%, primary assisted patency was 82% and 77% and secondary patency was 89% and 72% at 12 and 24 months follow up respectively.

CONCLUSION

For long femoropopliteal TASC C/D lesions, RSFAE appears to be a minimally invasive hybrid procedure with acceptable perioperative morbidity, low mortality, and acceptable patency rates. RSFAE should be considered an alternative to open surgery or a bridge to bypass procedure.

Endovascular Treatment and Outcomes for Femoropopliteal In-Stent Restenosis: Insights from the XLPAD Registry

Background

There is limited "real-world" evidence examining treatment modalities and outcomes in patients with symptomatic peripheral arterial disease undergoing endovascular treatment of femoropopliteal (FP) in-stent restenosis (ISR).

Materials and Methods

We compared outcomes in 2,895 patients from the XLPAD registry (NCT01904851) between 2006 and 2019 treated for FP ISR (n = 347) and non-ISR (n = 2,548) lesions. Primary endpoint included major adverse limb events (MALE) at 1 year, a composite of all-cause death, target limb repeat revascularization, or major amputation.

Results

ISR patients were more frequently on antiplatelet (94.5% vs 89.4%, p=0.007) and statin (68.9% vs 60.3%, p=0.003) therapies. Lesion length was similar (ISR: 145 ± 99 mm vs. non-ISR: 142 ± 99 mm, p=0.55). Fewer treated ISR lesions were chronic total occlusions (47.3% vs. 53.7%, p=0.02) and severely calcified (22.4% vs. 44.7%, p < 0.001). Atherectomy (63.5% vs. 45.0%, p < 0.001) and drug-coated balloons (DCB; 4.7% vs. 1.7%, p < 0.001) were more frequently used in ISR lesions. The distal embolization rate was higher in ISR lesions (2.4% vs. 0.9%, p=0.02). Repeat revascularization (21.5% vs. 16.7%, p=0.04; Figure) was higher and freedom from MALE at 1 year was significantly lower (87% vs. 92.5%, p < 0.001) in the ISR group.

Conclusion

Atherectomy and DCB are more frequently used to treat FP ISR lesions. Patients with FP ISR have more intraprocedural distal embolization, higher repeat revascularization procedures, and lower freedom from MALE at 1 year.

Avoiding the Deep Plantar Arterial Arch in Transmetatarsal Amputations: A Cadaver Study

BACKGROUND

The deep plantar arterial arch (DPAA) is formed by an anastomosis between the deep plantar artery and the lateral plantar artery. The potential risk of injury to the DPAA is concerning when performing transmetatarsal amputations, and care must be taken to preserve the anatomy. We sought to determine the positional anatomy of the DPAA based on anatomical landmarks that could be easily identified and palpated during transmetatarsal amputation.

METHODS

In an effort to improve our understanding of the positional relationship of the DPAA to the distal metatarsal parabola, dissections were performed on 45 cadaveric feet to measure the location of the DPAA with respect to the distal metatarsal epiphyses. Images of the dissected specimens were digitally acquired and saved for measurement using in-house-written software. The mean, SD, SEM, and 95% confidence interval were calculated for all of the measurement parameters and are reported on pooled data and by sex. An independent-samples t test was used to assess for sex differences. Interrater reliability of the measurements was estimated using the intraclass correlation coefficient.

RESULTS

The origin of the DPAA was located a mean ± SD of 35.6 ± 3.9 mm (95% confidence interval, 34.5-36.8 mm) proximal to the perpendicular line connecting the first and fifth metatarsal heads. The average interrater reliability across all of the measurements was 0.921.

CONCLUSIONS

This study provides the positional relationship of the DPAA with respect to the distal metatarsal parabola. This method is easily reproducible and may assist the foot and ankle surgeon with surgical planning and approach when performing partial pedal amputation.

Technical perspectives in the management of complex infrainguinal arterial chronic total occlusions

BACKGROUND

The prevalence and incidence of peripheral arterial disease have been increasing in the general population. Although limited data are available on the epidemiology of chronic limb-threatening ischemia, it likely represents <10% of all patients with peripheral arterial disease. In the general population, its overall prevalence has been 0.74%. This specific subgroup of patients can have severe disease presentations. Their symptoms often correlate with a specific infrainguinal morphologic pattern known as chronic total occlusion (CTO). CTO will often be difficult to cross in a standard endovascular fashion. In previous years, several techniques have been developed to overcome the limitations of standard antegrade endoluminal or subintimal approaches, if these approaches fail.

METHODS

We have described the advanced techniques, including subintimal techniques, such as crush balloon, parallel wire, SAFARI (subintimal arterial flossing with antegrade and retrograde intervention), and double-balloon techniques, in detail. Furthermore, we have described a homemade reentry device, which can be used to provide access to the distal true lumen in extreme, uncrossable cases. Retrograde approaches comprise several techniques developed from interventional cardiology techniques. Finally, we have described transcollateral and pedal-plantar loop techniques in detail.

RESULTS

These techniques allow endovascular surgeons to successfully encounter even complex anatomies, which will be present in ∼80% of all CTOs. In the present report, we have reviewed all these advanced techniques, correlated the effectiveness of each with the proximal and distal cap morphologic features, and discussed the economic consequences of the endovascular approach considering the costs vs the disease progression and the materials used during the procedures.

CONCLUSIONS

Effective use of the advanced techniques we have described is of paramount importance because only 20% of patients will have a CTO that is crossable using standard techniques. Thus, the use of these techniques can help endovascular surgeons increase their success for patients with complex anatomic patterns. Furthermore, the possibility of treating these CTOs using only guidewires and catheters will reduce the costs of the procedures. However, their use in clinical practice still must be standardized.

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

PURPOSE

To compare retrograde plantar-arch and transpedal-access approach for revascularization of below-the-knee (BTK) arteries in patients with critical limb ischemia (CLI) after a failed antegrade approach.

MATERIALS AND METHODS

Retrospectively we identified 811 patients who underwent BTK revascularization between 1/2014 and 1/2020. In 115/811 patients (14.2%), antegrade revascularization of at least 1 tibial artery had failed. In 67/115 (58.3%), patients retrograde access to the target vessel was achieved via the femoral access and the plantar-arch (PLANTAR-group); and in 48/115 patients (41.7%) retrograde revascularization was performed by an additional retrograde puncture (TRANSPEDAL-group). Comorbidities, presence of calcification at pedal-plantar-loop/transpedal-access-site, and tibial-target-lesion was recorded. Endpoints were technical success (PLANTAR-group: crossing the plantar-arch; TRANSPEDAL-group: intravascular placement of the pedal access sheath), procedural success [residual stenosis <30% after plain old balloon angioplasty (POBA)], and procedural complications limb salvage and survival. Correlations between calcification at access site/tibial-target-lesion and technical/procedural-success were tested.

RESULTS

Technical success was achieved in 50/67 (75%) patients of the PLANTAR-group and in 39/48 (81%) patients of the TRANSPEDAL-group (p=0.1). Procedural success was obtained in 23/67 (34%) patients of the PLANTAR-group and in 25/48 (52%) patients of the TRANSPEDAL-group (p=0.04). In 14/49 (29%) cases with calcification at the pedal-plantar loop, technical success was not achieved (p=0.04), and in 33/44 (75%) patients with calcification at the tibial-target-lesion, procedural success was not attained (PLANTAR-group) (p=0.026). In the TRANSPEDAL-group, correlations between calcification at access site/tibial-target-lesion and technical/procedural-success were not observed (p=0.2/p=0.4). In the PLANTAR-group, minor complications occurred in 13/67 (19%) and in the TRANSPEDAL-group in 4/48 patients (8%) (p=0.08). Limb salvage at 12 (18) months was 90% (82%) (PLANTAR-group; 95%CI 15.771-18.061) and 84% (76%) (TRANSPEDAL-group; 95%CI 14.475-17.823) (Log-rank p=0.46). Survival at 12 (18) months was 94% (86%) (PLANTAR-group; 95%CI 16.642-18.337) and 85% (77%) (TRANSPEDAL; 95%CI 14.296-17.621) (Log-rank p=0.098).

CONCLUSION

Procedural success was significantly higher using the transpedal-access approach. Calcifications at pedal-plantar loop and target-lesion significantly influenced technical/procedural failure using the plantar-arch approach. No significant difference between both retrograde techniques in terms of feasibility, safety, and limb salvage/survival was found.

Transradial endovascular intervention: Results from the Radial accEss for nAvigation to your CHosen lesion for Peripheral Vascular Intervention (REACH PVI) study

BACKGROUND/PURPOSE

The transradial approach has been proposed as an alternative to traditional transfemoral access for diagnostic and therapeutic purposes in several catheterization procedures. Historically, extended length devices for lower limb endovascular interventions have been limited. The aim of this study was to investigate the acute clinical outcomes of orbital atherectomy (OA) via transradial access (TRA) for the treatment of lower extremity peripheral artery disease (PAD).

METHODS/MATERIALS

REACH PVI was a multicenter, prospective, observational study (NCT03943160) including subjects with PAD and target lesion morphology appropriate for OA. All patients were followed post-procedure through the first standard of care follow-up visit.

RESULTS

A total of 50 patients were enrolled. In most cases the indication for intervention was disabling claudication (74.0%). Overall, 50 target lesions were treated, 92.0% of lesions were femoropopliteal and 8.0% were infrapopliteal. The average lesion length was 98.3 ± 87.5 mm and 78.0% of the lesions were severely calcified. Balloon angioplasty was performed in 98.0% of target lesions, while a stent was deployed in 16.0%. Treatment success was 98.0%; in only one case the result was sub-optimal (>30% stenosis with stent placement) and a significant dissection was reported. No serious distal embolization, serious thrombus formation or serious acute vessel closure were observed intra- or post-procedurally.

CONCLUSIONS

Transradial OA followed by percutaneous transluminal angioplasty for lower extremity PAD is feasible and demonstrates a favorable safety profile. Extended length devices such as the Extended Length Orbital Atherectomy System could further facilitate transradial endovascular procedures by increasing its spectrum of application.

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

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.

Physician experts in diabetes are natural team leaders for managing diabetic patients with foot complications. A position statement from the Italian diabetic foot study group

Diabetic foot syndrome (DFS) is a complex disease. The best outcomes are reported with the multi-disciplinary team (MDT) approach, where each member works collaboratively according to his/her expertise. However, which health provider should act as the team leader (TL) has not been determined. The TL should be familiar with the management of diabetes, related complications and comorbidities. He/she should be able to diagnose and manage foot infections, including prompt surgical treatment of local lesions, such as abscesses or phlegmons, in an emergent way in the first meeting with the patient. According to the Organization for Economic Co-operation and Development (OECD) reports, Italy is one of countries with a low amputation rate in diabetic patients. Many factors might have contributed to this result, including 1)the special attention directed to diabetes by the public health system, which has defined diabetes as a "protected disease", and accordingly, offers diabetic patients, at no charge, the best specialist care, including specific devices, and 2)the presence of a network of diabetic foot (DF) clinics managed by diabetologists with medical and surgical expertise. The health care providers all share a "patient centred model" of care, for which they use their internal medicine background and skills in podiatric surgery to manage acute or chronic needs in a timely manner. Therefore, according to Italian experiences, which are fully reported in this document, we believe that only a skilled diabetologist/endocrinologist should act as a TL. Courses and university master's degree programmes focused on DF should guarantee specific training for physicians to become a TL.

Outcomes of Pedal Artery Angioplasty Are Independent of the Severity of Inframalleolar Disease: A Subanalysis of the Multicenter RENDEZVOUS Registry

Purpose: To examine the efficacy of pedal artery angioplasty (PAA) for chronic limb-threatening ischemia (CLTI) according to the severity of inframalleolar disease. Methods: In total, 257 consecutive CLTI patients (mean age 73.2 years; 175 men) with de novo infrapopliteal and inframalleolar artery disease were enrolled from the retrospective RENDEZVOUS registry. Inframalleolar artery disease was classified as moderate (Kawarada type 2, 144 patients) or severe (Kawarada type 3, 113 patients). PAA was performed in 140 patients: 66 (45.8%) with moderate disease and 74 (65.5%) with severe disease. The remaining 117 patients (78 with moderate disease and 39 with severe disease) underwent interventions that did not include PAA. The primary outcomes were the wound healing and limb salvage rates at 12 months after the initial treatment. The outcomes of the PAA and no-PAA groups were examined to determine any correlation between treatment efficacy and baseline disease severity. Results: The success rates of PAA among the patients with moderate and severe inframalleolar disease were 89.4% and 87.8%, respectively (p=0.683). The wound healing rate at 12 months was significantly higher in the PAA group than in the no-PAA group regardless of the severity of inframalleolar disease [moderate: 58.8% vs 40.0% (p=0.049); severe: 59.6% vs 33.2% (p=0.021), respectively]. The worst limb salvage rate (76.9%) was seen among patients in the no-PAA group with severe inframalleolar disease (no-PAA/moderate: 94.8%; PAA/moderate: 90.9%; and PAA/severe: 87.8%, p=0.028). Conclusion: PAA improves the wound healing rate of patients with CLTI regardless of the severity of inframalleolar disease. This treatment modality also might improve limb salvage rates in patients with severe inframalleolar disease affecting both the anterior and posterior pedal circulations.

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.

Functional prognosis of critical limb ischemia and efficacy of restoration of direct flow below the ankle

Objective

Patients with critical limb ischemia have serious systemic comorbidities and are at high risk of impairment of limb function. In this study, we assessed the prognostic factors of limbs after revascularization.

Methods

In this retrospective single-center cohort study, from April 2008 to December 2012, we treated 154 limbs of 121 patients with critical limb ischemia by the endovascular therapy-first approach based on the patients’ characteristics. The primary end point was amputation-free survival. Secondary end points were patency of a revascularized artery, major adverse limb events, or death. Furthermore, we investigated the ambulatory status one year after revascularization as prognosis of limb function.

Results

Endovascular therapy was performed in 85 limbs in 65 patients as the initial therapy (endovascular therapy group) and surgical reconstructive procedures (bypass group) were performed in 69 limbs in 56 patients. Early mortality within 30 days was not observed in either group. The primary patency rate was significantly better in the bypass group than in the endovascular therapy group ( p < 0.0001). Furthermore, the secondary patency rate was similar between the two groups ( p = 0.0096). There were no significant differences in amputation-free survival and major adverse limb event between the two groups. Univariate analysis showed that ulcer healing ( p < 0.0001), no hypoalbuminemia ( p = 0.0019), restoration of direct flow below the ankle ( p = 0.0219), no previous cerebrovascular disease ( p = 0.0389), and Rutherford 4 ( p = 0.0469) were predictive factors for preservation of ambulatory status one year after revascularization. In multivariate analysis, ulcer healing ( p < 0.0001) and restoration of direct flow below the ankle ( p = 0.0060) were significant predictors.

Conclusions

Ulcer healing and restoration of direct flow below the ankle are independently associated with prognosis of limb functions in patients who undergo infrainguinal arterial reconstruction.

Tips for pedal access: technical evolution and review

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.

Critical limb ischemia: current challenges and future prospects

Critical limb ischemia (CLI) is considered the most severe pattern of peripheral artery disease. It is defined by the presence of chronic ischemic rest pain, ulceration or gangrene attributable to the occlusion of peripheral arterial vessels. It is associated with a high risk of major amputation, cardiovascular events and death. In this review, we presented a complete overview about physiopathology, diagnosis and holistic management of CLI. Revascularization is the first-line treatment, but several challenging cases are not treatable by conventional techniques. Unconventional techniques for the treatment of complex below-the-knee arterial disease are described. Furthermore, the state-of-the-art on gene and cell therapy for the treatment of no-option patients is reported.

Patency of the arterial pedal-plantar arch in patients with chronic kidney disease or diabetes mellitus

BACKGROUND

Patency of the pedal-plantar arch limits risk of amputation in peripheral artery disease (PAD). We examined patients without chronic kidney disease (CKD)/diabetes mellits (DM) [PAD-control], those with DM without CKD, and those with CKD without DM.

METHOD

Uni- and multivariate logistic regression was used to assess association of CKD with loss of patency of the pedal-plantar arch and presence of tibial or peroneal vessel occlusion. Multivariate models adjusted for age, sex, hypertension, hyperlipidemia and smoking.

RESULTS

A total of 419 patients were included [age 75.2 ± 10.3 years, 288 (69%) male]. CKD nearly doubled the unadjusted odds ratio (OR) for loss of patency of the pedal-plantar arch. After adjustment, association remained significant for severe CKD [estimated glomerular filtration rate (eGFR) ≤ 29 ml/min compared with eGFR ≥ 60 ml/min, adjusted (adj.) OR 8.24 (95% confidence interval {CI} 0.99-68.36, p = 0.05)]. CKD was not related to risk of tibial or peroneal artery occlusion [PAD-control versus CKD, adj. OR 1.09 (95% CI 0.49-2.44, p = 0.83)] in contrast to DM [PAD-control versus DM, adj. OR 2.41 (95% CI 1.23-4.72, p = 0.01), CKD versus DM, adj. OR 2.21 (95% CI 0.93-5.22); p = 0.07)].

CONCLUSIONS

Below the knee (BTK) vascular pattern differs in patients with either DM or CKD alone. Severe CKD is a risk factor for loss of patency of the pedal-plantar arch.

Clinical Outcomes of Pedal Artery Angioplasty for Patients With Ischemic Wounds: Results From the Multicenter RENDEZVOUS Registry

OBJECTIVES

The aim of this study was to investigate the clinical outcomes of pedal artery angioplasty (PAA) for patients with critical limb ischemia.

BACKGROUND

Pedal artery disease is considered a predictor of delayed wound healing (DH) after endovascular therapy. Adjunctive PAA might improve the speed and extent of wound healing.

METHODS

Consecutive patients with critical limb ischemia (n = 257) presenting with de novo infrapopliteal and pedal artery disease were retrospectively reviewed from a multicenter registry. Patients were divided into 2 groups according to whether PAA was performed (n = 140) or not (n = 117). The rate of wound healing and time to wound healing were compared between these groups. DH score was calculated using the number of independent predictors of DH. Patients were stratified into 3 groups according to DH score: low risk (DH score = 0), moderate risk (DH score = 1 or 2), and high risk (DH score = 3). Estimated efficacy was analyzed for each risk-stratified population.

RESULTS

The rate of wound healing was significantly higher (57.5% vs. 37.3%, p = 0.003) and time to wound healing significantly shorter (211 days vs. 365 days; p = 0.008) in the PAA group. In a multivariate analysis, nonambulatory status, target wound depth (UT grade ≥2), and daily hemodialysis were revealed as predictors of DH. In the moderate-risk population, adjunctive PAA significantly improved the rate of wound healing (59.3% vs. 33.9%; p = 0.001). In the high-risk population, however, PAA did not affect wound healing.

CONCLUSIONS

Patients who underwent PAA showed a higher rate of wound healing and shorter time to wound healing, especially in the moderate-risk population. With regard to wound healing, this aggressive strategy might become a salvage procedure for patients with critical limb ischemia presenting with pedal artery disease.

Inframalleolar Intervention for Limb Preservation

Critical limb ischemia (CLI) is a relatively prevalent and highly morbid condition. Patients with CLI have a poor prognosis, especially in the setting of incomplete revascularization. Traditionally, achieving optimal revascularization has been limited by the high prevalence of small-vessel disease in this population. More recently, advanced endovascular techniques, increased operator experience, and new technologies have enabled complete revascularization of inframalleolar disease with encouraging clinical results. In this article, we present an approach to endovascular therapy for inframalleolar revascularization of patients with CLI.

Predictors for Better Blood-Flow Restoration of Long-Segmental Below-the-Knee Chronic Total Occlusions after Endovascular Therapy in Diabetic Patients

OBJECTIVE

To prospectively investigate predictors for good restoration of blood flow of below-the-knee (BTK) chronic total occlusions (CTOs) after endovascular therapy in diabetes mellitus (DM) patients.

MATERIALS AND METHODS

A total of 120 long-segmental (≥ 5 cm) BTK, CTOs in 81 patients who underwent recanalization were included in this study. After angioplasty, blood-flow restoration was assessed using modified thrombolysis in myocardial ischemia grades and classified as good flow (grade 3) and poor flow (grade 1/2). One hundred and six CTOs with successful recanalization were divided into a good flow group (GFG; n = 68) and poor flow group (PFG; n = 38). Multivariate logistic regression analyses were undertaken to determine independent predictors of blood-flow restoration. Receiver operating characteristic curves were constructed to determine the best cutoff value. The prevalence of target-lesion restenosis during follow-up was compared between two groups.

RESULTS

Univariate analyses suggested that CTOs in GFG were characterized by lighter limb ischemia (p = 0.03), shorter course of ischemic symptoms (p < 0.01) and lesion length (p = 0.04), more frequent use of intraluminal angioplasty (p = 0.03), and higher runoff score (p < 0.01) than those in PFG. Multivariate regression analyses suggested that distal runoffs (p = 0.001; odds ratio [OR], 10.32; 95% confidence interval [CI]: 4.082-26.071) and lesion length (p < 0.001; OR, 1.26; 95% CI: 1.091-1.449) were independent predictors for good flow restoration. Kaplan-Meier analyses at 12 months showed a higher prevalence of non-restenosis in GFG (p < 0.01).

CONCLUSION

Distal runoffs and lesion length are independent predictors for good flow restoration for long-segmental BTK, CTOs in DM patients who receive endovascular therapy.

Clinical Implications of Additional Pedal Artery Angioplasty in Critical Limb Ischemia Patients With Infrapopliteal and Pedal Artery Disease

PURPOSE

To evaluate the clinical implications of additional pedal artery angioplasty (PAA) for patients with critical limb ischemia (CLI).

METHODS

Twenty-nine patients (mean age 77.8±8.6 years; 21 men) with CLI (32 limbs) presenting with de novo infrapopliteal and pedal artery (Kawarada type 2/3) disease were reviewed. The need for PAA was based on the existence of sufficient wound blush (WB) around the target wounds after conventional above-the-ankle revascularization. Fourteen patients with insufficient WB in 14 limbs received additional PAA, while 15 patients with sufficient WB in 18 limbs did not. The groups were compared for overall survival, limb salvage, and amputation-free survival within 1 year after the procedure. The wound healing rate, time to wound healing, and freedom from reintervention rate were also evaluated.

RESULT

The success rate of additional PAA was 93% (13/14). All limbs with successful PAA achieved sufficient WB (13/13). Despite insufficient WB before the additional PAA, overall survival (86% vs 73%, p=0.350), limb salvage (93% vs 83%, p=0.400), amputation-free survival (79% vs 53%, p=0.102), and freedom from reintervention (64% vs 73%, p=0.668) rates were similar in both groups. Furthermore, the wound healing rate (93% vs 60%, p=0.05) was higher and time to wound healing (86.0±18.7 vs 152.0±60.2 days, p=0.05) was shorter in the patients who received PAA.

CONCLUSION

Additional PAA might improve the WB and clinical outcomes (especially speed and extent of wound healing) in patients with CLI attributed to infrapopliteal and pedal artery disease.

Angiosomes: how do they affect my treatment?

The number of diabetic patients is actually increasing all around the world, consequently, critical limb ischemia and ischemic diabetic foot disorders related to the presence of diabetic occlusive arterial disease will represent in the next few years a challenging issue for vascular specialists. Revascularization represents one step in the treatment for the multidisciplinary team, reestablishing an adequate blood flow to the wound area, essential for healing and avoiding major amputations. The targets of revascularization can be established to obtain a "complete" revascularization, treating all tibial and foot vessels or following the angiosome and wound-related artery model, obtaining direct blood flow for the wound. In this article, we summarize our experience in endovascular treatment of diabetic critical limb ischemia, focusing on the angiosome and wound-related artery model of revascularization and the technical challenges in treating below-the-knee and below-the-ankle vessels.

Runoff Detected by Magnetic Resonance Angiography as an Indicator for Better Recanalization Outcomes in Below-the-Knee Chronic Total Occlusions in Diabetic Patients

Purpose: To compare the feasibility and efficacy of recanalizing below-the-knee (BTK) chronic total occlusions (CTOs) between patients with good or poor distal runoff based on magnetic resonance angiography (MRA) scans. Methods: Two hundred long-segment BTK CTOs in 171 limbs of 113 diabetic patients (58 men; mean age 69.8±1.9 years) were divided into good distal runoff (GDR: 119 lesions, 98 limbs) or poor distal runoff groups (PDR: 81 lesions, 73 limbs) based on baseline MRA findings. After angioplasty, modified thrombolysis in myocardial ischemia (mTIMI) grades and ankle-brachial index (ABI) were used to assess immediate outcomes. Regularly scheduled duplex or MRA imaging was performed in follow-up. The restenosis and limb salvage rates were compared. Results: The success rates were 93.3% and 87.7% in the GDR and PDR groups, respectively (p=0.21); subintimal angioplasty was more common in the PDR group (93.0% vs. 63.1%, p<0.01). Completion angiography indicated an mTIMI grade 3 blood flow in 71.2% lesions in the GDR patients and in 52.1% in the PDR (p=0.01) group. Improvement in the ABI was greater in the GDR limbs (p<0.001 vs. PDR). Mean imaging follow-up was 10.8±6.9 months in the GDR group and 11.1±6.6 months in the PDR group. Kaplan-Meier analysis showed a better restenosis-free rate in the GDR group (80.6% vs. 61.7%; p=0.02) at 12 months and for lesions with mTIMI grade 3 flow (p<0.01). At 24 months, Kaplan-Meier analysis revealed a better limb salvage rate in the GDR group (84.2% vs. 54.6%; p=0.02). Conclusion: Distal runoff detected using MRA could be a predictor for successful intraluminal recanalization, better distal tissue perfusion, improved long-term patency, and better limb salvage for patients with BTK CTOs.

Infrapopliteal arterial recanalization: A true advance for limb salvage in diabetics

The world is facing an epidemic of diabetes; consequently in the next years, critical limb ischemia (CLI) due to diabetic arterial disease, characterized by multiple and long occlusions of below-the-knee (BTK) vessels, will become a major issue for vascular operators. Revascularization is a key therapy in these patients as restoring adequate blood supply to the wound is essential for healing, thus avoiding major amputations. Endoluminal therapy for BTK arteries is now a key part of the vascular specialist armamentarium. Tibial artery endovascular approaches have been shown to achieve high limb salvage rates with low morbidity and mortality and endovascular interventions one should now consider to be the first line treatment in the majority of CLI patients, especially in those with associated medical comorbidities. To do so, the vascular specialist requires detailed knowledge of the BTK endovascular techniques and devices. The first step decision in tibial endovascular therapy is access. In this context, the anterograde ipsilateral approach is generally preferred. The next critical decision is the choice of the vessel(s) to be approached in order to achieve successful limb salvage. Obtaining pulsatile flow to the correct portion of the foot is the paramount for ulcer healing. As such, a good understanding of the current angiosome model should enhance clinical results. The devices used should be carefully selected and optimal choice of guide wire is also extremely important and should be based on the characteristics of the lesion (location, length, and stenosis/occlusion) together with the characteristics of the guide wire itself (tip load, stiffness, hydrophilic/hydrophobic coating, flexibility, torque transmission, trackability, and pushability). Passing through chronic total occlusions can be quite challenging. The vascular interventional radiologist needs therefore to master the techniques that have been recently described: anterograde approaches, including the drilling technique, the penetrating technique, the subintimal technique and the parallel technique; subintimal arterial flossing with anterograde-retrograde procedures (Safari); the pedal-plantar loop technique and revascularization through collateral fibular artery vessels.

Contemporary crossing techniques for infrapopliteal chronic total occlusions

The synergism of technical refinement and advanced technology has significantly increased the popularity of infrapopliteal intervention. Since chronic total occlusion (CTO) is a common disorder among patients with symptomatic infrapopliteal artery disease, infrapopliteal CTO intervention is now evolving rapidly in the field of endovascular intervention. Guidewire crossing through the CTO is essential for a successful procedure. We review up-to-date infrapopliteal CTO crossing techniques based on the current literature.

Treating calf and pedal vessel disease: the extremes of intervention

Recent developments in catheter, balloon, and guidewire technology have increased the scope for endovascular treatments in the management of complex and challenging disease in the calf and foot. The antegrade femoral approach remains the starting point for most interventions, but there is a growing role for procedures performed from unconventional access such as the pedal arteries. This article reviews the indications for intervention, atypical access, and the choice of equipment for these extreme interventions.

Retrograde transplantar arch angioplasty of below-the-knee arterial occlusions: outcomes compared to anterograde recanalization

RATIONALE AND OBJECTIVES

To compare the clinical outcomes of retrograde transplantar arch angioplasty and conventional below-the-knee (BTK) anterograde recanalization.

MATERIALS AND METHODS

One hundred twelve limbs in 96 patients underwent attempt at antegrade tibial angioplasty. Among 27 technical failures, retrograde trans-dorsal or -planter percutaneous transluminal angioplasty was attempted in 22 limbs. Ankle-brachial index (ABI), thrombolysis in myocardial infarction (TIMI) flow grade, and dorsal/plantar arterial pulse score improvement were compared immediately after the procedures between patients received successful anterograde angioplasty (anterograde angioplasty group [AAG], 85 limbs in 71 patients) and retrograde angioplasty (retrograde angioplasty group [RAG], 22 limbs in 20 patients). Target vessel restenosis and limb salvage were observed during follow-up.

RESULTS

Primary technical success rate was 75.9% in the RAG (vs. 74.0% AAG, P > .05). ABI improved from 0.55 ± 0.21 to 0.93 ± 0.19 in the RAG (vs. 0.56 ± 0.14 to 0.89 ± 0.18 AAG, P > .05). TIMI flow grade demonstrated greater reperfusion of distal foot tissue in the RAG (2.3 ± 0.8 vs. 1.0 ± 0.8, P < .05). Primary patency rates at 12 and 24 months were 63.6% (14 of 22) and 45.5% (10 of 22) in the RAG and 52.9% (45 of 85) and 37.6% (32 of 85) in the AAG, respectively (P > .05). Kaplan-Meier analysis after 24 months found limb salvage rates of 93.8% in the RAG and 96.5% in the AAG (P > .05).

CONCLUSIONS

Retrograde transplantar arch angioplasty achieved better immediate blood flow and similar ABI improvement, primary patency rate, and limb salvage rate compared to conventional transtibial angioplasty for BTK occlusions. This could become a supplementary technique when anterograde angioplasty fails.

Retrograde pedal access for patients with critical limb ischemia

OBJECTIVE

Retrograde pedal access may allow the treatment of tibial occlusive lesions when standard endovascular techniques fail. We aimed to analyze the outcomes in patients with chronic limb ischemia (Rutherford class IV and V) who were not surgical candidates for a tibial bypass and had undergone an unsuccessful attempt at revascularization through an antegrade access.

METHODS

During a 3-year period, a retrograde pedal access was selectively chosen when a popliteal or tibial lesion could not be crossed through an antegrade approach. Retrograde pedal access was performed under ultrasound guidance using a 4F micropuncture coaxial sheath. All interventions were performed in a sheathless fashion using a 0.014- or 0.018-inch "bareback" wire as support for a 2- or 2.5-mm balloon angioplasty catheter to cross and treat tibial chronic total occlusions that could not be treated through an antegrade approach. Routine anticoagulation and dual-antiplatelet therapy were used periprocedurally. Antegrade access was used to treat any lesion that required a stent placement after the retrograde wire was snared and brought through the antegrade guidecatheter. Patient indications and comorbidities were recorded. Outcomes analyzed were limb salvage rate, periprocedural complications, and mortality. Mean and standard deviations were calculated. The Kaplan-Meier method was used to calculate limb salvage rates.

RESULTS

A review of the 681 lower extremity angiograms in which a patient had an intervention from July 2010 through December 2013 identified 13 patients (nine men) in whom a retrograde pedal access was performed (mean age, 71.4 ± 12.4 years). Among these, diabetes was present in 10 of 13 (77%) and chronic renal insufficiency (stages II-V) in nine (69%). Five (38%) had undergone contralateral amputation. Indications for a retrograde pedal revascularization were Rutherford chronic limb ischemia class IV in two (15%) and class V in 11 (85%). Technical success rate was 69% (nine of 13). A variety of popliteal (two of 13) and tibial (13 of 13) vessels were treated with angioplasty alone (10 of 13) or angioplasty/stent placement (three of 13) through a retrograde approach. The technical failures were due to inability to cross the occlusion(s). Periprocedurally, there was one myocardial infarction but no local complications, worsening renal insufficiency, or deaths. At a mean follow-up of 17.1 ± 10.3 months, the limb salvage rate was 77% (10 of 13). There was a high mortality rate of 23% (three of 13) on follow-up in this cohort, occurring at median 6 ± 4 months.

CONCLUSIONS

Retrograde pedal access for limb salvage in high-risk patients is feasible and safe, with acceptable limb salvage rates at intermediate follow-up. Appropriate candidates are those who have failed an antegrade intervention and are poor candidates for a tibial bypass. Future studies should test whether this mode of revascularization has favorable limb salvage rates in larger patient populations and seek to identify specific patient populations who will benefit from this technique.

Treatment of infrapopliteal critical limb ischemia in 2013: the wound perfusion approach

The primary goals of treatment for critical limb ischemia (CLI) are alleviation of ischemic rest pain, healing of arterial insufficiency ulcers, and improving quality of life. These goals are directed toward preventing limb loss and CLI-related mortality. Arterial revascularization serves as the foundation of a contemporary approach to promote amputation-free survival. Mounting evidence supports a wound-directed angiosome revascularization approach, increasingly achieved with endovascular techniques. Innovations in technology and wound-perfusion strategy have advanced patient care and are accelerating the pace of CLI treatment. The evolving angiosome revascularization approach has been augmented with a multidisciplinary wound care strategy that deserves particular emphasis. These state-of-the-art advances in CLI management are reported herein with considerations for the future treatment of CLI.

The clinical utility of below-the-ankle angioplasty using "transmetatarsal artery access" in complex cases of CLI

OBJECTIVES

To appraise clinical results of foot arteries recanalization using percutaneous retrograde transmetatarsal arteries access followed by retrograde recanalization of foot and tibial vessels.

BACKGROUND

Arterial revascularization by means of percutaneous transluminal angioplasty (PTA) is a mainstay in the management of patients with critical limb ischemia (CLI). Nonetheless, when employing standard approaches, success rate remain suboptimal. We report the clinical results of foot arteries recanalization through transmetatarsal artery access.

METHODS

From September 2011 to November 2012, 38 patients (28 men; mean age 73.2 ± 11.4 years) underwent transmetatarsal artery access after antegrade recanalization failure, followed by retrograde recanalization of the foot and tibial vessels. The primary end point was TcPO₂ improvement. The secondary end point was limb salvage rate, amputation-free survival rate and radiation exposure.

RESULTS

Technical success (ability to deliver the balloon across the lesion and inflate it at nominal pressure) was achieved in 33 (86.84%) of cases, with <50% residual stenosis and no complications. Failures were because of spasm or no true lumen re-entry. During follow-up (mean 6.7 ± 2.3 months/range 1-14) clinical improvement was observed in the patients having technical success, with TcPO₂ increasing, from 10.3 ± 7.6 to 50.7 ± 8.2 mm Hg, avoiding major amputations. Amputation-free survival rate calculated by Kaplan-Meier analysis was 81.5% at 12 months. Radiation exposition was major than in patients treated by antegrade way (45.5 ± 56.1 vs. 52.5 ± 11.5 min of fluoroscopy and 69.1 ± 83.2 vs. 94 ± 26.5 Gym(2) of X-ray dose; P < 0.001).

CONCLUSION

Transmetatarsal artery access appears feasible and beneficial in cases with a failed antegrade recanalization and unsuitable for retrograde pedal/plantar access.