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Retrograde Proximal Anterior Tibial Artery Access for Treating Femoropopliteal Segment Occlusion: A Novel Approach
Retrograde Proximal Anterior Tibial Artery Access for Treating Femoropopliteal Segment Occlusion: A Novel Approach Breno Boueri Affonso,1 Fernanda Uchiyama Golghetto Domingos,2 Joaquim Maurı´cio da Motta Leal Filho,1 Macello Jose Sampaio Maciel,2 Rafael Noronha Cavalcante,2 Edgar Bortolini,1 and Francisco Cesar Carnevale,2 S~ao Paulo, S~ao Paulo, Brazil
Some challenges have been detected when there are long and complex lesions of femoropopliteal arterial occlusive disease, even with descriptions of the retrograde pedal approaches. The aim of this article is to describe the retrograde proximal anterior tibial artery access for treatment of femoropopliteal segment occlusion when antegrade recanalization failed (retrograde recanalization and rearranging the system into an antegrade position). Technical and clinical success was achieved in 100% of 4 cases, with an improvement of at least 2 Rutherford classes. Minor complication, small hematoma in an anterior compartment of the limb, occurred in 1 patient. No sign of compartmental syndrome was observed.
INTRODUCTION Endovascular revascularization is a widely accepted treatment modality for occlusive arterial disease in patients with critical limb ischemia because of its lower morbidity and mortality rates. Despite antegrade recanalization techniques, several challenges persist when treating long-segment femoropopliteal arterial occlusive disease (more than 15 cm with multiple stenoses or chronic total occlusion with or without heavy calcification).1,2 In 1990, Lyer et al. described a retrograde pedal access technique for revascularization of infrainguinal arterial occlusive disease when antegrade recanalization failed. As a result, the overall success rates increased.3,4 After the description by Lyer et al.,
many other approaches have been described in the literature; such as a percutaneous retrograde distal tibial access,1e7 a retrograde popliteal,7e9 retrograde peroneal,2,7 and intravascular transcollateral approach.5 However, failure rates for occlusive lesions remain high, ranging from 20% to almost 40%.3 The purpose of this article is to describe retrograde proximal anterior tibial (RPAT) artery access as a novel approach for treating femoropopliteal segment occlusion when anterograde recanalization fails. Our hospital’s institutional review board did not require approval for this brief report.
TECHNIQUE 1
Interventional Radiology Unit, Department of Radiology, Heart Institute, University of S~ao Paulo Medical School, S~ao Paulo, SP, Brazil. 2 Interventional Radiology Unit, Radiology Institute, Hospital das Clı´nicas, University of S~ao Paulo Medical School, S~ao Paulo, SP, Brazil.
Correspondence to: Joaquim Maurı´cio da Motta Leal Filho, MD, PhD, Rua Tuim, 783, apto. 151, Vila Uberabinha, S~ao Paulo, SP 04514-103, Brazil; E-mail: [email protected] Ann Vasc Surg 2016; 33: 237–244 http://dx.doi.org/10.1016/j.avsg.2015.11.021 Ó 2016 Elsevier Inc. All rights reserved. Manuscript received: August 11, 2015; manuscript accepted: November 26, 2015; published online: February 21, 2016.
The technique consisted of the following procedures: an angiographic study of the patient was performed. Fluoroscopic guidance was used to identify the anterior tibial (AT) artery (road mapping). A 21-gauge needle was used to puncture the proximal segment of the AT artery based on the associated anatomic parameters (extensor digitorum longus muscle, tibialis anterior musclee Fig. 1), an ultrasound to guide the puncture can also be used at this stage. An angiogram was performed to ensure placement into the true lumen 237
238 Affonso et al.
Annals of Vascular Surgery
An 80 mg/kg bolus of intravenous heparin, 100 mg of oral acetylsalicylic acid, and 300 mg of oral clopidogrel were used at the beginning of the procedures. After the procedure, all patients undergoing a stent placement received 75 mg of clopidogrel daily for at least 3 months in addition to 100 mg of acetylsalicylic acid daily.
CASE REPORTS We retrospectively reviewed, from April 2013 to April 2015, 4 cases of long femoropopliteal occlusions in which RPAT artery access were used. Case 1
Fig. 1. Angiotomography in axial view of the lower limb, with anatomic parameters: extensor digitorum longus muscle (black asterisk), tibialis anterior muscle (white asterisk), tibia (black arrow head ), fibula (white arrow head ), and anterior tibial artery (white arrow).
of the artery (Fig. 2A) and a 0.018-inch guidewire (Boston, Marlborough, MA, USA) was inserted through the needle (Fig. 2B). The needle was pulled out. The AT artery was catheterized with a 4F-vertebral catheter (Terumo, Tokyo, Japan or Merit Medical System, South Jordan UT, USA) directly through the skin without using an introducer. A retrograde recanalization of the femoropopliteal occlusion was performed, and an angiogram was performed from the proximal introducer to confirm it (Fig. 3). The guidewire was passed directly through the distal end (tip located on the right common femoral artery) of the contralateral guiding introducer sheath (introduced from the left common femoral artery; super arrow-flex contralateral sheath introducer 45 cm; Teleflex, Athlone, Co Westmeath, Ireland) without a snare (Fig. 4). The system was rearranged into a proper anterograde position. The 0.018-inch guidewire was passed into the distal AT artery. The catheter was removed from the puncture site. Anterior tibial artery access hemostasis: externally, digital compression of the site puncture was applied, and at the same time, internally, a catheter-balloon was promptly inflated for 5 min (Fig. 5). Finally, the treatment of the femoropopliteal occlusion was performed (Figs. 6 and 7).
A 73-year-old man with ischemic rest pain (Rutherford 4) and an arteriography showing occlusion from the origin of popliteal artery until the emergence of AT artery (TransAtlantic Inter-Society Consensus [TASC] D) and 130mm occlusion length. The antegrade recanalization was not possible despite of multiples attempts, including a vessel perforation. After proximal AT artery puncture and retrograde recanalization, the lesion was treated with stent angioplasty Pulsar 18, 4 150 mm (Biotronik, B€ ulach, Switzerland). Pedal pulse was observed in the end of the procedure and an improvement to mild claudication (Rutherford 1) after 6 months of follow-up. Case 2 A 85-year-old woman with minor tissue loss (Rutherford 5) and an arteriography showing severe stenosis of the proximal anastomoses of a previous femoropopliteal bypass followed by occlusion of the proximal popliteal segment artery (TASC B) and 35-mm occlusion length. Initially, the proximal anastomoses were treated with balloon angioplasty, but the popliteal lesion was not crossed by antegrade recanalization. The RPAT access was attempted, and the lesion was treated with stent angioplasty, Pulsar 35, 5 60 mm (Biotronik, B€ ulach, Switzerland). Pedal pulse was observed in the end of the procedure and an improvement of Rutherford classification (Rutherford 3) after 12 months of follow-up. Case 3 A 53-year-old woman with ischemic rest pain (Rutherford 4) and an arteriography showing an intrastent occlusion of superficial femoral artery (SFA) and popliteal artery (TASC D) and 280-mm occlusion length. Antegrade recanalization was not successful. The RPAT access and retrograde recanalization were attempted, and the lesion was treated by balloon-catheter angioplasty, Passeo 18, 4 150 mm and 5 150 mm (Biotronik, B€ ulach, Switzerland). Pedal pulse was observed in the end of the procedure and an improvement to mild claudication (Rutherford 2) after 6 months of follow-up.
Volume 33, May 2016
Retrograde proximal anterior tibial access in SFA occlusions 239
Fig. 2. (A) Angiogram from the retrograde puncture of the AT artery with 21G needle to confirm the true lumen. (B) A 0.018-inch guidewire was inserted through the needle into the artery.
Case 4 A 71-year-old man with minor tissue loss (Rutherford 5) and an arteriography showing total occlusion of SFA and popliteal artery (TASC D) having 360-mm occlusion length. Antegrade recanalization was not successful. The RPAT was used for recanalization, and the lesion was treated with stent angioplasty, Pulsar 35, 5 150 mm or 5 120 mm or 5 80 mm or 6 60 mm or 6 120 mm (Biotronik, B€ ulach, Switzerland). Pedal pulse was observed in the end of the procedure, and an improvement to severe claudication (Rutherford 3) was observed in the 3 months follow-up. The initial antegrade approach used in the 4 cases depends on the level of injury in the SFA. If the level of occlusion was close to the bifurcation of the femoral arteries then the antegrade approach was performed by contralateral femoral access. But, if the level of occlusion in the SFA is close to popliteal artery then the antegrade
approach could be performed by ipsilateral femoral access. Technical success was defined as a successful crossing of the occlusive segment and achievement of an in-line flow to the pedal vessel, and it was reached in 100%. Clinical success was defined as improvement of at least 2 classes in the Rutherford classification, and it was reached in 100%. At the last follow-up, all the patients had pedal pulse and the same Rutherford class improvement. The mean follow-up was 6.8 months. Procedural complications were defined according to the Society of Interventional Radiology Clinical Practice Guidelines.10 No major complications were observed. A minor complication of a small hematoma in an anterior compartment of the limb occurred in one patient, which resulted in light pain for 3 days. The local pain was controlled with metamizole, a cold compress twice a day and rest. No signal of compartmental syndrome was observed.
240 Affonso et al.
Fig. 3. Digital subtraction angiogram performed from the proximal introducer to confirm the retrograde recanalization of the femoropopliteal occlusion and showing a good runoff (fibular and posterior tibial arteries).
DISCUSSION Endovascular revascularization has been increasingly used as a method to treat infrainguinal arterial occlusive disease. However, the expected technical success for antegrade infrainguinal interventions ranges from 56 to 97%.2 To increase the rate of success, some retrograde approaches have been developed.1,2,7,9
Annals of Vascular Surgery
Several advantages of retrograde access have been described. First, it has been proposed in the cardiac literature that the distal part of an occlusion might have less fibrotic or calcific tissue, which allows for the easier passage of a guidewire into the occlusion. Second, when an access point into a vessel is very close to the occlusive lesion, this approach provides more control and pushability of the wire through the occlusion.1,7,9 Third, the small diameter of a tibial vessel (2e3 mm) also helps improve the pushability of the catheter.7 Fourth, these techniques use basic tools available in an endovascular suite and are less costly than reentry devices.7 Occlusion of the access site due to thrombosis or spasm could require immediate surgical revascularization, which carries a risk of finding the impaired distal segment of the artery for conventional surgery.1,4,5,7 To minimize those risks, some authors prefer using only a low-profile sheath or micropuncture kits.2,11 Some prefer not using a sheath and only using low-profile devices, such as a 3F or 4F catheter or catheter balloon1,4,7,9,11 or an inner dilator of a 4F sheath.5 We adopted low-profile devices to support the guidewire and used an inner 4F-dilator or 4F-vertebral catheter directly through the skin to support the recanalization. We believe that an RPAT approach has many advantages over the distal access to treat femoropopliteal occlusions, such as a lower risk of local infection or lesion of the ischemic area by being located in a more perfused area far from infection sites. Furthermore, this approach maintains the integrity of the distal artery segment for further surgical treatment, if surgery becomes necessary. Another advantage of this approach is a larger caliber of the proximal AT artery compared with the distal area, which favors catheterization. The superficial localization and anatomic parameters of the small area contributes to the successful access of the proximal AT and digital compression for hemostasis. A lesion in the femoropopliteal segment is closer to the puncture site, which allows for easier pushability and torque delivery compared with more distal vessel access. Potential risks of this access procedure are local bleeding and compartmental syndrome. To minimize these risks, a minimum number of punctures should be attempt. In addition, adequate hemostasis should be performed using a catheter-balloon internally associated to digital compression externally. Because of the small diameter of the tibial vessel, retrograde access is only used to cross a lesion and not for an entire procedure. Therefore, it is important to rearrange a retrograde system into an
Volume 33, May 2016
Retrograde proximal anterior tibial access in SFA occlusions 241
Fig. 4. After crossing the occlusion, (A, B) the guidewire was passed directly through distal end (tip located on the right common femoral artery) of the contralateral
guiding sheath introducer (introduced from the left common femoral arteryesuper arrow-flex contralateral sheath introducer 45 cm) and (C) was captured.
anterograde position and use low-profile devices, which decrease the risk of injury to the vessel, vasospasm, and thromboses.1,2,4,5,7,11 In this study, retrograde intraluminal traversal was successful in 100% of the cases. However, we believe that a subintimal traversal could be attempted if an intraluminal traversal fails, as described in the literature for other distal access approaches.1,6,7,9,11 Finally, percutaneous distal access has been performed using either ultrasound or fluoroscopic guidance.1e7 Ultrasound-guided access limits radiation exposure to an operator and contrast material used, in addition to allowing the simultaneous, real-time ultrasound visualization of the vessel.2e4 However, an operator has to be familiar with an ultrasound. A vessel can roll away on contact with the tip of the access needle,4 and a large size probe can be bulky, which can interfere in the access process. We must also consider the echogenicity of the needle tip.2 A fluoroscopic approach with road mapping is easier for deeper or heavily calcified vessel. Operators should take care to avoid as much radiation as possible by using a pulse flow, short exposure times, and all appropriate available shielding.5,8,11 An experienced interventionist can determine which method should be used. In conclusion, RPAT access seems safe and feasible, and it could be another option for infrapopliteal access approach improving the treatment of complex femoropopliteal lesions when antegrade recanalization fails.
REFERENCES 1. El-Sayed. Retrograde pedal/tibial artery access for treatment of infragenicular arterial occlusive disease. Methodist Debakey Cardiovasc J 2013;9. 2. Sabri SS, Hendricks N, Stone J, et al. Retrograde pedal access technique for revascularization of infrainguinal arterial occlusive disease. J Vasc Interv Radiol 2015;26:29e38. 3. Rogers RK, Dattilo PB, Garcia JA, et al. Retrograde approach to recanalization of complex tibial disease. Catheter Cardiovasc Interv 2011;77:915e25. 4. Botti CF Jr, Ansel GM, Silver MJ, et al. Percutaneous retrograde tibial access in limb salvage. J Endovasc Ther 2003;10:614e8. 5. Montero-Baker M, Schmidt A, Braunlich S, et al. Retrograde approach for complex popliteal and tibioperoneal occlusions. J Endovasc Ther 2008;15:594e604. 6. Spinosa DJ, Harthun NL, Bissonette EA, et al. Subintimal Arterial Flossing with Anterograde-Retrograde Intervention (SAFARI) for subintimal recanalization to treat chronic critical limb ischemia. J Vasc Interv Radiol 2005;16:37e44. 7. Bazan HA, Le L, Donovan M, et al. Retrograde pedal access for patients with critical limb ischemia. J Vasc Surg 2014;60: 375e82. 8. Tonnossen KH, Sager P, Karle A. Percutaneous transluminal angioplasty of the superficial femoral artery by retrograde catheterization via the popliteal artery. Cardiovasc Intervent Radiol 1988;11:127e31; TASC TransAtlantic Inter-Society Consensus (TASC). Management of peripheral arterial disease (PAD). Eur J Vasc Endovasc Surg 2000;19:208e90. 9. Schmidt A, Bausback Y, Piorkowski M, et al. Retrograde recanalization technique for use after failed antegrade angioplasty in chronic femoral artery occlusions. J Endovasc Ther 2012;19:23e9. 10. Sacks D, McClenny TE, Cardella JF, et al. Society of Interventional Radiology clinical practice guidelines. J Vasc Interv Radiol 2003;14:199e202. 11. Gandini R, Pipitone V, Stefanini M, et al. The ‘‘safari’’ technique to perform difficult subintimal infragenicular vessels. Cardiovasc Intervent Radiol 2007;30:469e73.
242 Affonso et al.
Fig. 5. An appropriate balloon catheter gently dilated in the site of the puncture associated with manual compression until hemostasis.
Annals of Vascular Surgery
Volume 33, May 2016
Fig. 6. After recanalization, (A) predilatation of the lesion was performed with a catheter balloon 4 40 mm in the popliteal artery. Note the guidewire
Retrograde proximal anterior tibial access in SFA occlusions 243
(0.018-inch) reinserted into the distal segment of the AT artery, below of puncture site. (B) Angiogram of popliteal artery after predilatation.
244 Affonso et al.
Annals of Vascular Surgery
Fig. 7. Case 1: (A) final angiogram showing femoropopliteal segment, (B) AT and peroneal arteries patency after treatment.
Some challenges have been detected when there are long and complex lesions of femoropopliteal arterial occlusive disease, even with descriptions of the retrograde pedal approaches. The aim of this article is to describe the retrograde proximal anterior tibial artery access for treatment of femoropopliteal segment occlusion when antegrade recanalization failed (retrograde recanalization and rearranging the system into an antegrade position). Technical and clinical success was achieved in 100% of 4 cases, with an improvement of at least 2 Rutherford classes. Minor complication, small hematoma in an anterior compartment of the limb, occurred in 1 patient. No sign of compartmental syndrome was observed.
INTRODUCTION Endovascular revascularization is a widely accepted treatment modality for occlusive arterial disease in patients with critical limb ischemia because of its lower morbidity and mortality rates. Despite antegrade recanalization techniques, several challenges persist when treating long-segment femoropopliteal arterial occlusive disease (more than 15 cm with multiple stenoses or chronic total occlusion with or without heavy calcification).1,2 In 1990, Lyer et al. described a retrograde pedal access technique for revascularization of infrainguinal arterial occlusive disease when antegrade recanalization failed. As a result, the overall success rates increased.3,4 After the description by Lyer et al.,
many other approaches have been described in the literature; such as a percutaneous retrograde distal tibial access,1e7 a retrograde popliteal,7e9 retrograde peroneal,2,7 and intravascular transcollateral approach.5 However, failure rates for occlusive lesions remain high, ranging from 20% to almost 40%.3 The purpose of this article is to describe retrograde proximal anterior tibial (RPAT) artery access as a novel approach for treating femoropopliteal segment occlusion when anterograde recanalization fails. Our hospital’s institutional review board did not require approval for this brief report.
TECHNIQUE 1
Interventional Radiology Unit, Department of Radiology, Heart Institute, University of S~ao Paulo Medical School, S~ao Paulo, SP, Brazil. 2 Interventional Radiology Unit, Radiology Institute, Hospital das Clı´nicas, University of S~ao Paulo Medical School, S~ao Paulo, SP, Brazil.
Correspondence to: Joaquim Maurı´cio da Motta Leal Filho, MD, PhD, Rua Tuim, 783, apto. 151, Vila Uberabinha, S~ao Paulo, SP 04514-103, Brazil; E-mail: [email protected] Ann Vasc Surg 2016; 33: 237–244 http://dx.doi.org/10.1016/j.avsg.2015.11.021 Ó 2016 Elsevier Inc. All rights reserved. Manuscript received: August 11, 2015; manuscript accepted: November 26, 2015; published online: February 21, 2016.
The technique consisted of the following procedures: an angiographic study of the patient was performed. Fluoroscopic guidance was used to identify the anterior tibial (AT) artery (road mapping). A 21-gauge needle was used to puncture the proximal segment of the AT artery based on the associated anatomic parameters (extensor digitorum longus muscle, tibialis anterior musclee Fig. 1), an ultrasound to guide the puncture can also be used at this stage. An angiogram was performed to ensure placement into the true lumen 237
238 Affonso et al.
Annals of Vascular Surgery
An 80 mg/kg bolus of intravenous heparin, 100 mg of oral acetylsalicylic acid, and 300 mg of oral clopidogrel were used at the beginning of the procedures. After the procedure, all patients undergoing a stent placement received 75 mg of clopidogrel daily for at least 3 months in addition to 100 mg of acetylsalicylic acid daily.
CASE REPORTS We retrospectively reviewed, from April 2013 to April 2015, 4 cases of long femoropopliteal occlusions in which RPAT artery access were used. Case 1
Fig. 1. Angiotomography in axial view of the lower limb, with anatomic parameters: extensor digitorum longus muscle (black asterisk), tibialis anterior muscle (white asterisk), tibia (black arrow head ), fibula (white arrow head ), and anterior tibial artery (white arrow).
of the artery (Fig. 2A) and a 0.018-inch guidewire (Boston, Marlborough, MA, USA) was inserted through the needle (Fig. 2B). The needle was pulled out. The AT artery was catheterized with a 4F-vertebral catheter (Terumo, Tokyo, Japan or Merit Medical System, South Jordan UT, USA) directly through the skin without using an introducer. A retrograde recanalization of the femoropopliteal occlusion was performed, and an angiogram was performed from the proximal introducer to confirm it (Fig. 3). The guidewire was passed directly through the distal end (tip located on the right common femoral artery) of the contralateral guiding introducer sheath (introduced from the left common femoral artery; super arrow-flex contralateral sheath introducer 45 cm; Teleflex, Athlone, Co Westmeath, Ireland) without a snare (Fig. 4). The system was rearranged into a proper anterograde position. The 0.018-inch guidewire was passed into the distal AT artery. The catheter was removed from the puncture site. Anterior tibial artery access hemostasis: externally, digital compression of the site puncture was applied, and at the same time, internally, a catheter-balloon was promptly inflated for 5 min (Fig. 5). Finally, the treatment of the femoropopliteal occlusion was performed (Figs. 6 and 7).
A 73-year-old man with ischemic rest pain (Rutherford 4) and an arteriography showing occlusion from the origin of popliteal artery until the emergence of AT artery (TransAtlantic Inter-Society Consensus [TASC] D) and 130mm occlusion length. The antegrade recanalization was not possible despite of multiples attempts, including a vessel perforation. After proximal AT artery puncture and retrograde recanalization, the lesion was treated with stent angioplasty Pulsar 18, 4 150 mm (Biotronik, B€ ulach, Switzerland). Pedal pulse was observed in the end of the procedure and an improvement to mild claudication (Rutherford 1) after 6 months of follow-up. Case 2 A 85-year-old woman with minor tissue loss (Rutherford 5) and an arteriography showing severe stenosis of the proximal anastomoses of a previous femoropopliteal bypass followed by occlusion of the proximal popliteal segment artery (TASC B) and 35-mm occlusion length. Initially, the proximal anastomoses were treated with balloon angioplasty, but the popliteal lesion was not crossed by antegrade recanalization. The RPAT access was attempted, and the lesion was treated with stent angioplasty, Pulsar 35, 5 60 mm (Biotronik, B€ ulach, Switzerland). Pedal pulse was observed in the end of the procedure and an improvement of Rutherford classification (Rutherford 3) after 12 months of follow-up. Case 3 A 53-year-old woman with ischemic rest pain (Rutherford 4) and an arteriography showing an intrastent occlusion of superficial femoral artery (SFA) and popliteal artery (TASC D) and 280-mm occlusion length. Antegrade recanalization was not successful. The RPAT access and retrograde recanalization were attempted, and the lesion was treated by balloon-catheter angioplasty, Passeo 18, 4 150 mm and 5 150 mm (Biotronik, B€ ulach, Switzerland). Pedal pulse was observed in the end of the procedure and an improvement to mild claudication (Rutherford 2) after 6 months of follow-up.
Volume 33, May 2016
Retrograde proximal anterior tibial access in SFA occlusions 239
Fig. 2. (A) Angiogram from the retrograde puncture of the AT artery with 21G needle to confirm the true lumen. (B) A 0.018-inch guidewire was inserted through the needle into the artery.
Case 4 A 71-year-old man with minor tissue loss (Rutherford 5) and an arteriography showing total occlusion of SFA and popliteal artery (TASC D) having 360-mm occlusion length. Antegrade recanalization was not successful. The RPAT was used for recanalization, and the lesion was treated with stent angioplasty, Pulsar 35, 5 150 mm or 5 120 mm or 5 80 mm or 6 60 mm or 6 120 mm (Biotronik, B€ ulach, Switzerland). Pedal pulse was observed in the end of the procedure, and an improvement to severe claudication (Rutherford 3) was observed in the 3 months follow-up. The initial antegrade approach used in the 4 cases depends on the level of injury in the SFA. If the level of occlusion was close to the bifurcation of the femoral arteries then the antegrade approach was performed by contralateral femoral access. But, if the level of occlusion in the SFA is close to popliteal artery then the antegrade
approach could be performed by ipsilateral femoral access. Technical success was defined as a successful crossing of the occlusive segment and achievement of an in-line flow to the pedal vessel, and it was reached in 100%. Clinical success was defined as improvement of at least 2 classes in the Rutherford classification, and it was reached in 100%. At the last follow-up, all the patients had pedal pulse and the same Rutherford class improvement. The mean follow-up was 6.8 months. Procedural complications were defined according to the Society of Interventional Radiology Clinical Practice Guidelines.10 No major complications were observed. A minor complication of a small hematoma in an anterior compartment of the limb occurred in one patient, which resulted in light pain for 3 days. The local pain was controlled with metamizole, a cold compress twice a day and rest. No signal of compartmental syndrome was observed.
240 Affonso et al.
Fig. 3. Digital subtraction angiogram performed from the proximal introducer to confirm the retrograde recanalization of the femoropopliteal occlusion and showing a good runoff (fibular and posterior tibial arteries).
DISCUSSION Endovascular revascularization has been increasingly used as a method to treat infrainguinal arterial occlusive disease. However, the expected technical success for antegrade infrainguinal interventions ranges from 56 to 97%.2 To increase the rate of success, some retrograde approaches have been developed.1,2,7,9
Annals of Vascular Surgery
Several advantages of retrograde access have been described. First, it has been proposed in the cardiac literature that the distal part of an occlusion might have less fibrotic or calcific tissue, which allows for the easier passage of a guidewire into the occlusion. Second, when an access point into a vessel is very close to the occlusive lesion, this approach provides more control and pushability of the wire through the occlusion.1,7,9 Third, the small diameter of a tibial vessel (2e3 mm) also helps improve the pushability of the catheter.7 Fourth, these techniques use basic tools available in an endovascular suite and are less costly than reentry devices.7 Occlusion of the access site due to thrombosis or spasm could require immediate surgical revascularization, which carries a risk of finding the impaired distal segment of the artery for conventional surgery.1,4,5,7 To minimize those risks, some authors prefer using only a low-profile sheath or micropuncture kits.2,11 Some prefer not using a sheath and only using low-profile devices, such as a 3F or 4F catheter or catheter balloon1,4,7,9,11 or an inner dilator of a 4F sheath.5 We adopted low-profile devices to support the guidewire and used an inner 4F-dilator or 4F-vertebral catheter directly through the skin to support the recanalization. We believe that an RPAT approach has many advantages over the distal access to treat femoropopliteal occlusions, such as a lower risk of local infection or lesion of the ischemic area by being located in a more perfused area far from infection sites. Furthermore, this approach maintains the integrity of the distal artery segment for further surgical treatment, if surgery becomes necessary. Another advantage of this approach is a larger caliber of the proximal AT artery compared with the distal area, which favors catheterization. The superficial localization and anatomic parameters of the small area contributes to the successful access of the proximal AT and digital compression for hemostasis. A lesion in the femoropopliteal segment is closer to the puncture site, which allows for easier pushability and torque delivery compared with more distal vessel access. Potential risks of this access procedure are local bleeding and compartmental syndrome. To minimize these risks, a minimum number of punctures should be attempt. In addition, adequate hemostasis should be performed using a catheter-balloon internally associated to digital compression externally. Because of the small diameter of the tibial vessel, retrograde access is only used to cross a lesion and not for an entire procedure. Therefore, it is important to rearrange a retrograde system into an
Volume 33, May 2016
Retrograde proximal anterior tibial access in SFA occlusions 241
Fig. 4. After crossing the occlusion, (A, B) the guidewire was passed directly through distal end (tip located on the right common femoral artery) of the contralateral
guiding sheath introducer (introduced from the left common femoral arteryesuper arrow-flex contralateral sheath introducer 45 cm) and (C) was captured.
anterograde position and use low-profile devices, which decrease the risk of injury to the vessel, vasospasm, and thromboses.1,2,4,5,7,11 In this study, retrograde intraluminal traversal was successful in 100% of the cases. However, we believe that a subintimal traversal could be attempted if an intraluminal traversal fails, as described in the literature for other distal access approaches.1,6,7,9,11 Finally, percutaneous distal access has been performed using either ultrasound or fluoroscopic guidance.1e7 Ultrasound-guided access limits radiation exposure to an operator and contrast material used, in addition to allowing the simultaneous, real-time ultrasound visualization of the vessel.2e4 However, an operator has to be familiar with an ultrasound. A vessel can roll away on contact with the tip of the access needle,4 and a large size probe can be bulky, which can interfere in the access process. We must also consider the echogenicity of the needle tip.2 A fluoroscopic approach with road mapping is easier for deeper or heavily calcified vessel. Operators should take care to avoid as much radiation as possible by using a pulse flow, short exposure times, and all appropriate available shielding.5,8,11 An experienced interventionist can determine which method should be used. In conclusion, RPAT access seems safe and feasible, and it could be another option for infrapopliteal access approach improving the treatment of complex femoropopliteal lesions when antegrade recanalization fails.
REFERENCES 1. El-Sayed. Retrograde pedal/tibial artery access for treatment of infragenicular arterial occlusive disease. Methodist Debakey Cardiovasc J 2013;9. 2. Sabri SS, Hendricks N, Stone J, et al. Retrograde pedal access technique for revascularization of infrainguinal arterial occlusive disease. J Vasc Interv Radiol 2015;26:29e38. 3. Rogers RK, Dattilo PB, Garcia JA, et al. Retrograde approach to recanalization of complex tibial disease. Catheter Cardiovasc Interv 2011;77:915e25. 4. Botti CF Jr, Ansel GM, Silver MJ, et al. Percutaneous retrograde tibial access in limb salvage. J Endovasc Ther 2003;10:614e8. 5. Montero-Baker M, Schmidt A, Braunlich S, et al. Retrograde approach for complex popliteal and tibioperoneal occlusions. J Endovasc Ther 2008;15:594e604. 6. Spinosa DJ, Harthun NL, Bissonette EA, et al. Subintimal Arterial Flossing with Anterograde-Retrograde Intervention (SAFARI) for subintimal recanalization to treat chronic critical limb ischemia. J Vasc Interv Radiol 2005;16:37e44. 7. Bazan HA, Le L, Donovan M, et al. Retrograde pedal access for patients with critical limb ischemia. J Vasc Surg 2014;60: 375e82. 8. Tonnossen KH, Sager P, Karle A. Percutaneous transluminal angioplasty of the superficial femoral artery by retrograde catheterization via the popliteal artery. Cardiovasc Intervent Radiol 1988;11:127e31; TASC TransAtlantic Inter-Society Consensus (TASC). Management of peripheral arterial disease (PAD). Eur J Vasc Endovasc Surg 2000;19:208e90. 9. Schmidt A, Bausback Y, Piorkowski M, et al. Retrograde recanalization technique for use after failed antegrade angioplasty in chronic femoral artery occlusions. J Endovasc Ther 2012;19:23e9. 10. Sacks D, McClenny TE, Cardella JF, et al. Society of Interventional Radiology clinical practice guidelines. J Vasc Interv Radiol 2003;14:199e202. 11. Gandini R, Pipitone V, Stefanini M, et al. The ‘‘safari’’ technique to perform difficult subintimal infragenicular vessels. Cardiovasc Intervent Radiol 2007;30:469e73.
242 Affonso et al.
Fig. 5. An appropriate balloon catheter gently dilated in the site of the puncture associated with manual compression until hemostasis.
Annals of Vascular Surgery
Volume 33, May 2016
Fig. 6. After recanalization, (A) predilatation of the lesion was performed with a catheter balloon 4 40 mm in the popliteal artery. Note the guidewire
Retrograde proximal anterior tibial access in SFA occlusions 243
(0.018-inch) reinserted into the distal segment of the AT artery, below of puncture site. (B) Angiogram of popliteal artery after predilatation.
244 Affonso et al.
Annals of Vascular Surgery
Fig. 7. Case 1: (A) final angiogram showing femoropopliteal segment, (B) AT and peroneal arteries patency after treatment.