Retrograde pedal access for patients with critical limb ischemia

Objective: Retrograde pedal access may allow the treatment of tibial occlusive lesions when standard endovascular techniques fail. We aimed to analyze the outcomes in patients with chronic limb ischemia (Rutherford class IV and V) who were not surgical candidates for a tibial bypass and had undergone an unsuccessful attempt at revascularization through an antegrade access.Methods: During a 3-year period, a retrograde pedal access was selectively chosen when a popliteal or tibial lesion could not be crossed through an antegrade approach. Retrograde pedal access was performed under ultrasound guidance using a 4F micropuncture coaxial sheath. All interventions were performed in a sheathless fashion using a 0.014- or 0.018-inch "bareback" wire as support for a 2-or 2.5-mm balloon angioplasty catheter to cross and treat tibial chronic total occlusions that could not be treated through an antegrade approach. Routine anticoagulation and dual-antiplatelet therapy were used periprocedurally. Antegrade access was used to treat any lesion that required a stent placement after the retrograde wire was snared and brought through the antegrade guidecatheter. Patient indications and comorbidities were recorded. Outcomes analyzed were limb salvage rate, periprocedural complications, and mortality. Mean and standard deviations were calculated. The Kaplan-Meier method was used to calculate limb salvage rates.Results: A review of the 681 lower extremity angiograms in which a patient had an intervention from July 2010 through December 2013 identified 13 patients (nine men) in whom a retrograde pedal access was performed (mean age, 71.4 +/- 12.4 years). Among these, diabetes was present in 10 of 13 (77%) and chronic renal insufficiency (stages II-V) in nine (69%). Five (38%) had undergone contralateral amputation. Indications for a retrograde pedal revascularization were Rutherford chronic limb ischemia class IV in two (15%) and class V in 11 (85%). Technical success rate was 69% (nine of 13). A variety of popliteal (two of 13) and tibial (13 of 13) vessels were treated with angioplasty alone (10 of 13) or angioplasty/ stent placement (three of 13) through a retrograde approach. The technical failures were due to inability to cross the occlusion(s). Periprocedurally, there was one myocardial infarction but no local complications, worsening renal insufficiency, or deaths. At a mean follow-up of 17.1 +/- 10.3 months, the limb salvage rate was 77% (10 of 13). There was a high mortality rate of 23% (three of 13) on follow-up in this cohort, occurring at median 6 +/- 4 months.Conclusions: Retrograde pedal access for limb salvage in high-risk patients is feasible and safe, with acceptable limb salvage rates at intermediate follow-up. Appropriate candidates are those who have failed an antegrade intervention and are poor candidates for a tibial bypass. Future studies should test whether this mode of revascularization has favorable limb salvage rates in larger patient populations and seek to identify specific patient populations who will benefit from this technique