Comparison of ante-versus retrograde access for the endovascular treatment of long and calcified, de novo femoropopliteal occlusive lesions

To compare antegrade versus retrograde recanalization, in terms of procedural time, radiation and contrast agent exposure, number and total length of implanted stents and procedural complications, in long and calcified, de novo femoropopliteal occlusions. We performed retrospective matching of prospectively acquired data by lesion length, occlusion length and lesion calcification by the peripheral arterial calcium scoring system (PACSS) score in patients who were referred for endovascular treatment due to symptomatic peripheral artery disease (PAD). Forty-two consecutive patients with antegrade and 23 patients with retrograde after failed antegrade recanalization were identified (mean lesion length = 32.1 ± 6.9 cm; mean occlusion length = 24.6 ± 7.7 cm; PACSS score = 3.25 ± 0.91). 23% of the patients had intermittent claudication, whereas 77% exhibited critical limb ischemia (CLI). Patients who underwent retrograde versus antegrade recanalization required a significantly lower number of stents (0.9 ± 1.0 versus 1.8 ± 1.4, p = 0.01) and a lower total stent length (6.8 ± 8.5 cm versus 11.7 ± 9.9 cm, p < 0.05) in the interest of more extensive coverage of the lesions using drug coated balloons (DCB) (28.5 ± 12.0 cm versus 18.2 ± 16.0 cm, p = 0.01). No re-entry device was required with the retrograde versus 9 of 42 (21%) with the antegrade recanalization group (p = 0.02). The rate of complications due to retrograde puncture was low (one patient with hematoma and one with distal pseudoaneurysm, both managed conservatively). In long and calcified femoropopliteal occlusions, the retrograde approach is associated with a lower number of re-entry devices and stents and with more extensive lesion coverage with DCB, in the interest of costs and possibly long-term patency.German Clinical Trials Register: DRKS00015277.

Endovascular treatment of diabetic foot ischemic ulcer - Technical review

This article is a technical review of the common techniques used in the treatment of lower-limb occlusive arterial disease associated with diabetes. The techniques described here reflect the author’s own practice and are methods that the author finds helpful in avoiding complications and in making the technical aspects of the procedures easier.

Mid-term outcomes of chronic total occlusion percutaneous coronary intervention with subadventitial vs. intraplaque crossing: A systematic review and meta-analysis

BACKGROUND

Some reports have demonstrated increased risk with subadventitial chronic total occlusion (CTO) crossing, whereas others suggest equipoise between subadventitial and intraplaque crossing techniques. We sought to clarify the effect of subadventitial lesion crossing on mid-term outcomes of CTO percutaneous coronary intervention (PCI).

METHODS

We conducted a systematic review and meta-analysis of studies reporting post-discharge outcomes after CTO PCI performed via subadventitial vs. intraplaque approaches.

RESULTS

Five studies comprising a total of 2,539 patients were included. Compared with intraplaque crossing (n=1,654, 65.1%), subadventitial cases (n=885, 34.9%) had a higher J-CTO score (2.9±1.2 vs. 1.6±1.2, p<0.001), and required significantly longer stent lengths (difference in means: 19.66 mm [95% confidence interval (CI), 11.23 to 28.08]; p<0.001). At a median follow-up of 12.0months, subadventitial CTO crossing was associated with a higher overall rate of target vessel revascularization (TVR, crude rate, 11.5% vs. 7.6%, odds ratio [OR]: 2.19 [95% CI, 1.62 to 2.95]; p<0.001); the risk was higher in studies of extensive compared with limited dissection and re-entry techniques (OR: 3.46 [95% CI: 2.24 to 5.36] vs. 1.52 [95% CI, 0.94 to 2.46], p_interaction=0.013). The rates of stent thrombosis, myocardial infarction, and cardiovascular mortality did not vary significantly between subadventitial and intraplaque crossing.

CONCLUSIONS

CTOs treated with subadventitial crossing were significantly more complex as compared with CTOs treated with intraplaque crossing. Extensive subadventitial crossing techniques were associated with higher TVR rates as compared with limited techniques, supporting the important role of limited techniques in the treatment of complex CTOs.

Popliteal versus tibial retrograde access for subintimal arterial flossing with antegrade-retrograde intervention (SAFARI) technique

OBJECTIVE

This study aimed to ascertain differences in benefit and effectiveness of popliteal versus tibial retrograde access in subintimal arterial flossing with the antegrade-retrograde intervention (SAFARI) technique.

METHODS

This was a retrospective study of SAFARI-assisted stenting for long chronic total occlusion (CTO) of TASC C and D superficial femoral lesions. 38 cases had superficial femoral artery lesions (23 TASC C and 15 TASC D). All 38 cases underwent SAFARI-assisted stenting. The ipsilateral popliteal artery was retrogradely punctured in 17 patients. A distal posterior tibial (PT) or dorsalis pedis (DP) artery was retrogradely punctured in 21 patients, and 16 of them were punctured after open surgical exposure.

RESULTS

SAFARI technical success was achieved in all cases. There was no significant difference in 1-year primary patency (75% vs. 78.9%, p = .86), secondary patency (81.2% vs. 84.2%, p = .91) and access complications (p = 1.00) between popliteal and tibial retrograde access. There was statistical difference in operation time between popliteal (140.1 ± 28.4 min) and tibial retrograde access with PT/DP punctures after surgical vessel exposure (120.4 ± 23.0 min, p = .04).

CONCLUSION

The SAFARI technique is a safe and feasible option for patients with infrainguinal CTO (TASC II C and D). The PT or DP as the retrograde access after surgical vessel exposure is a good choice when using the SAFARI technique.

Subintimal stent graft reconstruction of an infrarenal aortic occlusion

The traditional approach to revascularization in aortoiliac disease is surgical. Endovascular treatment techniques for revascularization have emerged in recent years and have resulted in less invasive options for management of vascular disease. In this article, we describe a novel approach to endovascular stent graft reconstruction of a heavily calcified infrarenal aortic occlusion. The interventional management of aortic occlusions is subsequently discussed.