Open Proximal Endarterectomy with Retrograde Access and Stenting: A Novel Technique for Lower Extremity Revascularization

Abstract

Background:

Treatment of chronic limb threatening ischemia (CLTI) poses a significant clinical challenge despite recent medical advancements. Chronic total occlusion (CTO) lesions make endovascular approaches to CLTI particularly challenging. Open proximal exposure with retrograde access and stenting (OPERAS) aims to solve this challenge through retrograde subintimal crossing of a CTO with direct visualization of proximal re-entry into the true lumen. We describe this novel technique and present its efficacy in eight patients.

Methods:

We conducted a retrospective case series at a single tertiary academic center. Data for patients who received OPERAS intervention included demographics, peri-operative details, and follow-up information. Statistical analysis was performed on length of stay, major post-operative complications, further intervention, clinical progression at 1 year, and amputation-free survival at 1 year. Immediate technical failure (ITF) and limb-based patency (LBP) at 1 year were calculated.

Results:

Nine limbs underwent OPERAS between January 2019 and March 2020. Inflow was achieved with common femoral artery endarterectomy. All limbs underwent balloon angioplasty and stenting of the SFA, and seven underwent the same procedure in the popliteal artery. ITF was 0% for all nine cases. There were no major post-operative complications, and ankle-brachial index significantly improved pre-and post-operatively (P < .001). Eight limbs (88.9%) sustained amputation-free survival at 1 year, and overall LBP was 67% at 1 year.

Conclusion:

Our study presents a hybrid revascularization option to address severe, anatomically complex limbs (GLASS III) that lack a single autogenous conduit for open surgical revascularization. OPERAS addresses a main point of technical failure of subintimal techniques by directly visualizing the wire in the true lumen. Our data suggest that OPERAS can be effective to: (1) improve technical success of luminal re-entry following a subintimal approach; (2) address inflow concurrently with severe femoropopliteal disease; and (3) can be utilized when distal tissue loss is involved.

Keywords

chronic limb threatening ischemia chronic total occlusion lower extremity revascularization global limb anatomic staging system

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References

Allison

Denenberg

, et al. Ethnic-specific prevalence of peripheral arterial disease in the United States. Am J Prev Med. 2007;32(4):328-333. doi:10.1016/j.amepre.2006.12.010.

Sigvant

Lundin

Wahlberg

. The risk of disease progression in peripheral arterial disease is higher than expected: a meta-analysis of mortality and disease progression in peripheral arterial disease. Eur J Vasc Endovasc Surg. 2016;51(3):395-403. doi:10.1016/j.ejvs.2015.10.022.

Norgren

Hiatt

Dormandy

Nehler

Harris

Fowkes

FGR

. Inter-society consensus for the management of peripheral arterial disease (TASC II). J Vasc Surg. 2007;45(1):S5-S67. doi:10.1016/j.jvs.2006.12.037.

Mustapha

Igyarto

O’Connor

, et al. One-year outcomes of peripheral endovascular device intervention in critical limb ischemia patients: sub-analysis of the LIBERTY 360 study. Vasc Health Risk Manag. 2020;16:57-66. doi:10.2147/VHRM.S230934.

Antoniou

Chalmers

Georgiadis

, et al. A meta-analysis of endovascular versus surgical reconstruction of femoropopliteal arterial disease. J Vasc Surg. 2013;57(1):242-253. doi:10.1016/j.jvs.2012.07.038.

Desai

Baronofsky

Shukla

Rahimi

. One-year freedom from amputation, survival, and cost of care following tibial and pedal endovascular interventions for critical limb ischemia: the role of atherectomy and drug-eluting stents. Ann Vasc Surg. Published online March 2020. doi:10.1016/j.avsg.2020.03.032.

Jaff

White

Hiatt

, et al. An update on methods for revascularization and expansion of the TASC lesion classification to include below-the-knee arteries: a supplement to the inter-society consensus for the management of peripheral arterial disease (TASC II). Vasc Med. 2015;20(5):465-478. doi:10.1177/1358863X15597877.

el Khoury

Edwards

, et al. The global limb anatomic staging system is associated with outcomes of infrainguinal revascularization in chronic limb threatening ischemia. J Vasc Surg. 2021;73(6):2009-2020.e4. doi:10.1016/j.jvs.2020.12.094.

Schanzer

Hevelone

Owens

, et al. Technical factors affecting autogenous vein graft failure: observations from a large multicenter trial. J Vasc Surg. 2007;46(6):1180-1190. doi:10.1016/j.jvs.2007.08.033.

10.

Kaushal

Roche-Nagle

Tan

, et al. Outcomes at a single center after subintimal arterial flossing with antegrade-retrograde intervention for critical limb ischemia. J Vasc Surg. 2018;67(5):1448-1454. doi:10.1016/j.jvs.2017.08.091.

11.

Kitrou

Parthipun

Diamantopoulos

Paraskevopoulos

Karunanithy

Katsanos

. Targeted true lumen re-entry with the outback catheter. J Endovasc Ther. 2015;22(4):538-545. doi:10.1177/1526602815594249.

12.

Testi

Ceccacci

Cevolani

Giacchi

Tarantino

Turicchia

. Femoral balloon oriented puncture for true lumen reentry in the common femoral artery after subintimal retrograde recanalization of superficial femoral artery ostial occlusion: the FORLEE technique. J Endovasc Ther. 2019;26(4):490-495. doi:10.1177/1526602819849722.

13.

Ichihashi

Nagatomi

Iwakoshi

Inagaki

Bolstad

Kichikawa

. Balloon-oriented puncture for creating an access for endovascular aortic aneurysm repair in a case of iliac and femoral artery occlusion. CVIR Endovasc. 2020;3(1):25. doi:10.1186/s42155-020-00116-3.

14.

Ozen

Zhu

Bhanot

Arslan

Turba

. Outcomes of subintimal arterial flossing with antegrade–retrograde intervention on patients with critical limb ischemia and tissue loss. Vasc Med. 2021;26(2):207-209. doi:10.1177/1358863X20964573.

15.

Haga

Shindo

Motohashi

, et al. Early evaluation of the infrainguinal revascularization strategy selection tool of the global vascular guidelines for chronic limb-threatening ischemia patients. J Vasc Surg. 2021;74(4):1253-1260.e2. doi:10.1016/j.jvs.2021.04.034.

16.

Al-Ameri

Clavijo

Matthews

Kloner

Shavelle

. Devices to treat peripheral chronic total occlusions. J Intervent Cardiol. 2012;25(4):395-403. doi:10.1111/j.1540-8183.2012.00727.x.

17.

Bausback

Botsios

Flux

, et al. Outback catheter for femoropopliteal occlusions: immediate and long-term results. J Endovasc Ther. 2011;18(1):13-21. doi:10.1583/10-3248.1.

18.

da Zhuang

Patel

Tan

, et al. Outcome and distal access patency in subintimal arterial flossing with antegrade-retrograde intervention for chronic total occlusions in lower extremity critical limb ischemia. J Vasc Intervent Radiol. 2020;31(4):601-606. doi:10.1016/j.jvir.2019.12.006.

19.

Darling

McCallum

Soden

, et al. Results for primary bypass versus primary angioplasty/stent for lower extremity chronic limb-threatening ischemia. J Vasc Surg. 2017;66(2):466-475. doi:10.1016/j.jvs.2017.01.024.

20.

Tokuda

Oba

Koshida

, et al. Validation of global limb anatomical staging system (GLASS) in patients with hemodialysis and Chronic Limb-Threatening Ischemia after endovascular treatment. Heart Ves. 2021;36(6):809-817. doi:10.1007/s00380-020-01747-1.