Comparison of ante-versus retrograde access for the endovascular treatment of long and calcified, de novo femoropopliteal occlusive lesions
- 57 Downloads
To compare antegrade versus retrograde recanalization, in terms of procedural time, radiation and contrast agent exposure, number and total length of implanted stents and procedural complications, in long and calcified, de novo femoropopliteal occlusions. We performed retrospective matching of prospectively acquired data by lesion length, occlusion length and lesion calcification by the peripheral arterial calcium scoring system (PACSS) score in patients who were referred for endovascular treatment due to symptomatic peripheral artery disease (PAD). Forty-two consecutive patients with antegrade and 23 patients with retrograde after failed antegrade recanalization were identified (mean lesion length = 32.1 ± 6.9 cm; mean occlusion length = 24.6 ± 7.7 cm; PACSS score = 3.25 ± 0.91). 23% of the patients had intermittent claudication, whereas 77% exhibited critical limb ischemia (CLI). Patients who underwent retrograde versus antegrade recanalization required a significantly lower number of stents (0.9 ± 1.0 versus 1.8 ± 1.4, p = 0.01) and a lower total stent length (6.8 ± 8.5 cm versus 11.7 ± 9.9 cm, p < 0.05) in the interest of more extensive coverage of the lesions using drug coated balloons (DCB) (28.5 ± 12.0 cm versus 18.2 ± 16.0 cm, p = 0.01). No re-entry device was required with the retrograde versus 9 of 42 (21%) with the antegrade recanalization group (p = 0.02). The rate of complications due to retrograde puncture was low (one patient with hematoma and one with distal pseudoaneurysm, both managed conservatively). In long and calcified femoropopliteal occlusions, the retrograde approach is associated with a lower number of re-entry devices and stents and with more extensive lesion coverage with DCB, in the interest of costs and possibly long-term patency.
German Clinical Trials Register: DRKS00015277.
KeywordsRetrograde access Long and calcified occlusive femoropopliteal lesions Pedal puncture Stent placement Atherectomy Drug-coated balloon Dissection re-entry Subintimal Intraluminal recanalization
Coronary artery disease
Common femoral artery
Critical limb ischemia
Drug coated balloons
Glomerular filtration rate
Highly sensitive troponin T
Peripheral artery disease
Peripheral arterial calcium scoring system
Superficial femoral artery
Transatlantic Intersociety Consensus
No funding was available for our study.
Compliance with ethical standards
Conflict of interest
No conflicts of interests to declare on behalf of all authors of this study.
- 1.Gallino A, Aboyans V, Diehm C, Cosentino F, Stricker H, Falk E, Schouten O, Lekakis J, Amann-Vesti B, Siclari F, Poredos P, Novo S, Brodmann M, Schulte KL, Vlachopoulos C, De Caterina R, Libby P, Baumgartner I, European Society of Cardiology Working Group on Peripheral Circulation (2014) Non-coronary atherosclerosis. Eur Heart J 35(17):1112–1119CrossRefPubMedGoogle Scholar
- 2.Fowkes FGR, Rudan D, Rudan I, Aboyans V, Denenberg JO, McDermott MM, Norman PE, Sampson UK, Williams LJ, Mensah GA, Criqui MH (2013) Comparison of global estimates of prevalence and risk factors for peripheral artery disease in 2000 and 2010: a systematic review and analysis. Lancet 382(9901):1329–1340CrossRefPubMedGoogle Scholar
- 3.Bradbury AW, Adam DJ, Bell J, Forbes JF, Fowkes FGR, Gillespie I, Ruckley CV, Raab GM, BASIL trial Participants (2010) Bypass versus angioplasty in severe ischaemia of the leg (BASIL) trial: an intention-to-treat analysis of amputation-free and overall survival in patients randomized to a bypass surgery-first or a balloon angioplasty-first revascularization strategy. J Vasc Surg 51(5 Suppl):5S–17SCrossRefPubMedGoogle Scholar
- 4.Fakhry F, Spronk S, van der Laan L, Wever JJ, Teijink JAW, Hoffmann WH, Smits TM, van Brussel JP, Stultiens GN, Derom A, den Hoed PT, Ho GH, van Dijk LC, Verhofstad N, Orsini M, van Petersen A, Woltman K, Hulst I, van Sambeek MR, Rizopoulos D, Rouwet EV, Hunink MG (2015) Endovascular revascularization and supervised exercise for peripheral artery disease and intermittent claudication: a randomized clinical trial. JAMA 314(18):1936–1944CrossRefPubMedGoogle Scholar
- 5.Greenhalgh RM, Belch JJF, Brown LC, Gaines PA, Gao L, Reise JA, Thompson SG, Mimic trial Participants (2008) The adjuvant benefit of angioplasty in patients with mild to moderate intermittent claudication (MIMIC) managed by supervised exercise, smoking cessation advice and best medical therapy: results from two randomised trials for stenotic femoropopliteal and aortoiliac arterial disease. Eur J Vasc Endovasc Surg 36(6):680–688CrossRefPubMedGoogle Scholar
- 7.Aboyans V, Ricco J-B, Bartelink M-LEL, Björck M, Brodmann M, Cohnert T, Aboyans V, Ricco JB, Bartelink MEL, Björck M, Brodmann M, Cohnert T, Collet JP, Czerny M, De Carlo M, Debus S, Espinola-Klein C, Kahan T, Kownator S, Mazzolai L, Naylor AR, Roffi M, Röther J, Sprynger M, Tendera M, Tepe G, Venermo M, Vlachopoulos C, Desormais I, ESC Scientific Document Group (2018) 2017 ESC guidelines on the diagnosis and treatment of peripheral arterial diseases, in collaboration with the European Society for Vascular Surgery (ESVS): Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteriesEndorsed by: the European Stroke Organization (ESO)The Task Force for the Diagnosis and Treatment of Peripheral Arterial Diseases of the European Society of Cardiology (ESC) and of the European Society for Vascular Surgery (ESVS). Eur Heart J 39(9):763–816CrossRefPubMedGoogle Scholar
- 12.Schmidt A, Bausback Y, Piorkowski M, Werner M, Bräunlich S, Ulrich M, Varcoe R, Friedenberger J, Schuster J, Botsios S, Scheinert D (2012) Retrograde recanalization technique for use after failed antegrade angioplasty in chronic femoral artery occlusions. J Endovasc Ther 19(1):23–29CrossRefPubMedGoogle Scholar
- 13.Walker CM, Mustapha J, Zeller T, Schmidt A, Montero-Baker M, Nanjundappa A, Manzi M, Palena LM, Bernardo N, Khatib Y, Beasley R, Leon L, Saab FA, Shields AR, Adams GL (2016) Tibiopedal access for crossing of infrainguinal artery occlusions: a prospective multicenter observational study. J Endovasc Ther 23(6):839–846CrossRefPubMedPubMedCentralGoogle Scholar
- 14.Diaz-Sandoval LJ, Soukas PA (2013) Popliteal arterial access. In: Dieter RS, Dieter RA Jr, Dieter RA III (eds) Endovascular interventions: a case-based approach. Springer, New York, pp 645–658Google Scholar
- 17.Montero-Baker M (2014) The retrograde approach for BTK chronic total occlusions. Endovasc Today 5:55–64Google Scholar
- 24.Malyar N, Fürstenberg T, Wellmann J, Meyborg M, Lüders F, Gebauer K, Bunzemeier H, Roeder N, Reinecke H (2013) Recent trends in morbidity and in-hospital outcomes of in-patients with peripheral arterial disease: a nationwide population-based analysis. Eur Heart J 34(34):2706–2714CrossRefPubMedGoogle Scholar
- 26.Noory E, Rastan A, Schwarzwälder U, Sixt S, Beschorner U, Bürgelin K, Neumann FJ, Zeller T (2009) Retrograde transpopliteal recanalization of chronic superficial femoral artery occlusion after failed re-entry during antegrade subintimal angioplasty. J Endovasc Ther 16(5):619–623CrossRefPubMedGoogle Scholar
- 28.Chin H’ng MW, Punamiya S (2014) An innovative modification of the retrograde approach to angioplasty and recanalization of the superficial femoral artery. Diagn Interv Radiol Ank Tur 20(2):164–167Google Scholar
- 35.Korosoglou G, Lichtenberg M, Celik S, Andrassy J, Brodmann M, Andrassy M (2018) The evolving role of drug-coated balloons for the treatment of complex femoropopliteal lesions. J Cardiovasc Surg (Torino) 59(1):51–59Google Scholar