Retrograde Access for Revascularization of Difficult Peripheral Artery Lesions in Patients with Chronic Limb-threatening Ischemia: A Periprocedural Outcome Analysis of a Single-center Case Series

Abstract

Background: Endovascular interventions are a standard treatment approach for patients suffering chronic limb threatening ischemia. This approach however can be complicated in some cases owing to difficult anatomy of the lesion that hinders successful crossing and recanalization of the diseased artery. Hence retrograde access and recanalization technique was described and used. Aims and Objectives: The aim of this study was to assess the procedural success, periprocedural complications and evaluate the safety of retrograde popliteal access for SFA and iliac lesions and tibial and pedal access for difficult tibial lesions. Materials and Methods: This is a case series of 60 patients who underwent percutaneous retrograde access (SFA, popliteal, tibial, pedal) for the recanalization of difficult lesions (aorto-iliac, SFA, tibial) between November 2018 to December 2022. We analyzed the technical success and number of periprocedural complications following successful revascularization through a prospective, nonrandomized, single–center, observational study conducted at Jain Institute of Vascular Sciences, Bengaluru, Karnataka, India. We have also analyzed safety of retrograde access and hemodynamic success (based on post-operative ABI improvement) following revascularization. Results: Of the 60 cases, retrograde access was successfully performed in all 60 patients, SFA in 3.3% (n=2), popliteal in 30% (n=18) (3 were primary PA retrograde access and remaining 15 were secondary), ATA was utilized in 35% (n=21), PTA in 20% (n=12), DPA in 6.7% (n=4) and peroneal in 5% (n=3). Technical success was achieved in 92% (n=55). Hemodynamic success was achieved in 75% (n=45). The recorded complication rate was 8.3% which included perforation of artery in 3% (n=2), iatrogenic AV fistula in 1.7% (n=1), arterial thrombosis in 1.7% (n=1) and peri-operative death in 1.7% (n=1). Conclusions: Hence, we recommend that retrograde access angioplasty is a safe and effective approach for revascularization when antegrade access fails and should be considered after proper anatomic evaluation, under US or fluoroscopic guidance.

Keywords

• critical limb ischemia
• minimal access angioplasty
• peripheral arterial disease
• retrograde access