Purpose: To describe the use and 1-year outcomes of retrograde pedal access during peripheral vascular interventions (PVI) for chronic limb-threatening ischemia (CLTI). Materials and Methods: From October 2016 to September 2017, 159 patients (mean age 71±10 years; 112 men) undergoing PVI via retrograde pedal access were enrolled in the multicenter Vascular Quality Initiative (VQI) registry. The pedal access approach included retrograde femoral (40%), antegrade femoral (26%), retrograde to antegrade femoral (22%), and pedal only (11%). A comparator group of 1972 patients (mean age 69±12 years; 1129 men) having a contralateral retrograde femoral access was established for propensity matching, which resulted in 156 patients per group. Procedure characteristics, technical success, and access site complications were compared. Major adverse limb events (MALE) and amputation-free survival (AFS) at 1 year were analyzed using the Kaplan-Meier method and Cox proportional hazard models to calculate hazard ratios (HR) and 95% confidence intervals (CI). Results: Technical failure was similar for retrograde femoral and pedal access (7% vs 13%, p=0.07). Complications were rare and included access site hematoma (2 vs 5, p=0.32) and target artery thrombosis (0 vs 2) for the femoral vs pedal access groups, respectively. The rates of MALE at 1 year were significantly lower after retrograde femoral access (24%) compared with pedal access (38%; log-rank p=0.01; HR 1.95, 95% CI 1.15 to 3.30). AFS estimates at 1 year were similar: 86% for retrograde femoral and 83% for pedal access (log-rank p=0.37; HR 1.32, 95% CI 0.73 to 2.39), as were major amputation estimates: 10% for retrograde femoral access and 13% for pedal access group (log-rank p=0.21; HR 1.58, 95% CI 0.77 to 3.26). Conclusion: In this analysis of multicenter registry data, retrograde pedal access in patients with CLTI had similar technical success and early complications in comparison with traditional contralateral retrograde femoral access. The rates of MALE were higher after pedal access but AFS was similar, indicating a tradeoff between limb salvage and repeat interventions.
DaviesMG.Critical limb ischemia: epidemiology. Methodist DeBakey Cardiovasc J. 2012;8:10–14.
2.
KudoTChandraFAKwunWH, et al. Changing pattern of surgical revascularization for critical limb ischemia over 12 years: endovascular vs. open bypass surgery. J Vasc Surg. 2006;44:304–313.
3.
IyerSSDorrosGZaitounR, et al. Retrograde recanalization of an occluded posterior tibial artery by using a posterior tibial cutdown: two case reports. Cathet Cardiovasc Diagn. 1990;20:251–253.
4.
SpinosaDJHarthunNLBissonetteEA, et al. Subintimal arterial flossing with antegrade-retrograde intervention (SAFARI) for subintimal recanalization to treat chronic critical limb ischemia. J Vasc Interv Radiol. 2015;16:37–44.
5.
MustaphaJASaabFMcGoffT, et al. Tibio-pedal arterial minimally invasive retrograde revascularization in patients with advanced vascular disease: the TAMI technique. Catheter Cardiovasc Interv. 2014;83:987–994.
6.
RuzsaZBellavicsRNemesB, et al. Combined transradial and transpedal approach for femoral artery interventions. JACC Cardiovasc Interv. 2018;11:1062–1071.
7.
Montero-BakerMSchmidtABraunlichS, et al. Retrograde approach for complex popliteal and tibioperoneal occlusions. J Endovasc Ther. 2008;15:594–604.
8.
KomshianSChengTFarberA, et al. Retrograde popliteal access to treat femoropopliteal artery occlusive disease. J Vasc Surg. 2018;68:161–167.
9.
WalkerCMMustaphaJZellerT, et al. Tibiopedal access for crossing of infrainguinal artery occlusions: a prospective multicenter observational study. J Endovasc Ther. 2016;23:839–846.
10.
CronenwettJLKraissLWCambriaRP.The Society for Vascular Surgery Vascular Quality Initiative. J Vasc Surg. 2012;55:1529–1537.
11.
BazanHALeLDonovanM, et al. Retrograde pedal access for patients with critical limb ischemia. J Vasc Surg. 2014;60:375–381.
12.
AmroAGabiAElhamdaniA, et al. Retrograde tibiopedal access as a bail-out procedure for endovascular intervention complications. Case Rep Vasc Med. 2016;2016:7519748.
13.
El-SayedHBennettMELohTM, et al. Retrograde pedal access and endovascular revascularization: a safe and effective technique for high-risk patients with complex tibial vessel disease. Ann Vasc Surg. 2016;31:91–98.
14.
KaushalARoche-NagleGTanKT, et al. Outcomes at a single center after subintimal arterial flossing with an antegrade-retrograde intervention for critical limb ischemia. J Vasc Surg. 2018;67:1448–1454.
15.
SabriSSHendricksNStoneJ, et al. Retrograde pedal access technique for revascularization of infrainguinal arterial occlusive disease. J Vasc Interv Radiol. 2015;26:29–38
16.
BottiCFAnselGMSilverMJ, et al. Percutaneous retrograde tibial access in limb salvage. J Endovasc Ther. 2003;10:614–618.
17.
KwanTWShahSAmorosoN, et al. Feasibility and safety of routine transpedal arterial access for treatment of peripheral artery disease. J Invasive Cardiol. 2015;27:327–330.
18.
RuzsaZNemesBBansaghiZ, et al. Transpedal access after failed anterograde recanalization of complex below-the-knee and femoropopliteal occlusions in critical limb ischemia. Catheter Cardiovasc Interv. 2013;83:997–1007.
19.
WellingRHABakkerOJScheinertD, et al. Below-the-knee retrograde access for peripheral interventions: a systematic review. J Endovasc Ther. 2018;25:345–352.
