Integrated application of antegrade and retrograde recanalization for femoral-popliteal artery chronic total occlusions: outcomes compared with antegrade recanalization

Evaluation of acute and midterm outcomes after complex combined antegrade/retrograde recanalization for occlusions of the femoropopliteal and infrapopliteal arteries

BACKGROUND

When antegrade recanalization of femoropopliteal and/or infrapopliteal occlusions fails, retrograde access has become an established option. To evaluate the results of combined antegrade and retrograde recanalization of femoropopliteal and infrapopliteal occlusions, patients undergoing secondary retrograde recanalization attempts were analyzed retrospectively.

METHODS

The primary end point was the success of the procedure (successful occlusion crossing using the antegrade/retrograde technique). Secondary end points include complication rate, primary patency and target lesion revascularization (TLR) rate, amputation rate, changes in ankle-brachial index, and Rutherford-Becker class. Predictors for procedure failure and TLR were analyzed.

RESULTS

We included 888 patients: 362 with femoropopliteal (group 1), 353 with infrapopliteal (group 2), and 173 with multilevel (group 3) recanalization. Critical limb-threatening ischemia was present in group 1, 2, and 3 in 36%, 62%, and 76% of patients, respectively. The intervention was successful in 92.5%, 93.8%, and 90.8% of the respective cases (P = .455). The overall peri-interventional complication rate was 7.2%. At 6, 12, and 24 months, primary patency was highest in group 1 (63.9%, 45.8%, and 33.3%), followed by group 3 (59.8%, 46.1%, and 33.3%), and group 2 (58.5%, 43.1%, and 30.4%; P = .537). The risk of undergoing repeated TLR within 24 months was 31.4% for group 1, 39.1% for group 2, and 45.7% for group 3. At 24 months, the survival rates in groups 1, 2, and 3 were 93.8%, 79.4%, and 87.5%, respectively. Over 24 months, 75 patients (8.4%) had to undergo amputation. Significant improvements in both ankle-brachial index and Rutherford-Becker class were present at discharge as well as at 6, 12, and 24 months (P < .001). Dialysis dependency was a predictor of unsuccessful antegrade/retrograde recanalization (P = .048). Lesion length (P = .0043), dialysis (P = .033), and recanalization level (P = .013) increase the risk of TLR.

CONCLUSIONS

Using a combined antegrade/retrograde access, recanalization of occluded femoropopliteal and/or infrapopliteal arteries can be achieved in a large number of cases. Owing to the high rate of repeated TLR across all lesion localizations, the indication for antegrade and retrograde recanalization may be limited to patients with critical limb-threatening ischemia.

Endovascular treatment for chronic total occlusion of superficial femoral artery: Is retrograde approach from popliteal artery effective and safe?

A 55-year-old male was admitted with numbness in the left foot and intermittent claudication. Doppler ultrasound and digital subtraction angiography presented chronic total occlusion in the ostial of left superficial femoral artery and reperfusion flow at one-third below from collateral channels of deep femoral artery. Thus, we decided to perform an endovascular intervention for this patient. First, we used contralateral transfemoral approach technique, but the microwire could not reach to the occluded superficial femoral artery lesion. Then, we approached the chronic total occlusion lesion retrogradely. A wire was passed successfully from the popliteal artery to ostial superficial femoral artery. Finally, 2 stents were implanted. This case highlights that popliteal retrograde approach is effective and safe for total occlusion of superficial femoral artery.

The "Pull, Cast, and Fix" Technique for Bypass in the Midpopliteal (P2) Arterial Segment in Chronic Femoropopliteal Occlusions

Femoropopliteal bypass operations can be difficult when the occlusive disease involves the superficial femoral artery and the popliteal arterial segment above the knee joint (supragenicular artery, P1). In case of lack of suitable vein graft or when the surgeon wishes to spare to infrapopliteal segment, the choice of the midpopliteal artery as anastomotic site becomes challenging because of its location. Moreover, totally endovascular recanalization procedures in such cases can be complex and demanding, whereas other reported hybrid revascularization techniques require advanced technical skills and raise significantly the cost. Therefore, we present our suggestion of a "pull, cast, and fix" technique to encounter these challenges and facilitate a successful bypass with a synthetic graft in the upper midpopliteal (P2) segment, combing a secure endarterectomy and anastomosis even under marginal visualization by means of securing the lumen with a soft feeding tube after the artery has been pulled via a Satinsky vascular clamp. Accordingly, the procedure is accomplished with placement of a flexible self-expandable stent in the midpopliteal artery through the synthetic graft.

Retrograde Recanalization of the Celiac Artery via the Pancreaticoduodenal Arcade as a Safe and Valid Alternative to Antegrade Access

PURPOSE

The antegrade recanalization of an occlusion or high-grade stenosis of the celiac artery via the aorta often represents a technical challenge. A retrograde approach via the superior mesenteric artery and the pancreaticoduodenal arcade may be an alternative approach. Based on our experience, we assess the technical success and the short- and mid-term outcomes of this bailout procedure.

METHODS

We performed a retrospective analysis of all consecutive patients who underwent recanalization and stent implantation in the celiac artery between January 2010 and December 2018. Data on vascular access, the materials used including stents, as well as the length of the intervention, radiation exposure, and follow-up were assessed.

RESULTS

Recanalization in combination with stent implantation into the celiac artery was performed in 43 patients. In 39 (91%) of 43 patients, the recanalization was successful with an antegrade approach via the aorta, whereas in 4 (9%) of 43 patients the passage of the stenosis was possible only through a retrograde approach through the superior mesenteric artery and the pancreaticoduodenal arcade followed be advancement of the microwire through the celiac artery into the aorta. The tip of the microwire was captured in the aorta with a snare and pulled out in the femoral introducer sheath and used as a guide for the antegrade implantation of a balloon-expandable stent.

CONCLUSIONS

The retrograde recanalization of the celiac artery via the pancreaticoduodenal arcade may be technically challenging yet represents a feasible alternative in case of a failed antegrade approach.