Interventional Radiology Unit, Foot & Ankle Clinic, Policlinico Abano Terme, Italy.
J Endovasc Ther. 2012 Dec;19(6):805-11. doi: 10.1583/JEVT-12-3998R.1.
To describe advanced retrograde access (transmetatarsal or transplantar arch) for endovascular treatment of critical limb ischemia (CLI) and foot salvage.
From September 2011 to March 2012, 28 CLI patients (24 men; mean age 71.9 ± 10.6 years) being treated for foot salvage had failed antegrade recanalization, and percutaneous retrograde access at the pedal or plantar artery was unavailable. Advanced retrograde access techniques were required to recanalize the target vessel to restore blood flow to the compromised tissue. After local administration of verapamil to control spasm, the first dorsal metatarsal artery was preferentially accessed with a 21-G needle. When the first metatarsal artery was occluded and not fluoroscopically viewable, the plantar arch was punctured directly. After puncture, a 0.018- or 0.014-inch guidewire and microsheath were inserted for retrograde recanalization of the foot and tibial arteries with balloons sized to the target vessels.
Retrograde transmetatarsal artery access was performed in 25 cases and direct transplantar arch access in 3. Technical success (ability to deliver the balloon across the lesion and inflate it at nominal pressure) was achieved in 24 (86%) cases, with <50% residual stenosis and no complications. The 4 technical failures were due to spasm or no true lumen re-entry after successful transmetatarsal (n=3) and transplantar arch access. During a mean 5-month follow-up (range 1-8), clinical improvement was obtained in the patients having technically successful tibial and foot artery recanalization; the transcutaneous pressure improved from 12.5 ± 6.7 to 49.8 ± 9.5 mmHg. There were no major and only 8 minor amputations. Amputation-free survival estimated by Kaplan-Meier analysis was 71% at 6 months. In patients with failed advanced access, the clinical condition did not improve.
The advanced retrograde access technique appears feasible and beneficial as a rescue strategy in challenging patients with a failed antegrade approach who are unsuitable for retrograde pedal/plantar access.
描述用于治疗严重肢体缺血（CLI）和足部挽救的腔内治疗的逆行高级入路（经跖骨或移植弓）。
2011 年 9 月至 2012 年 3 月，28 例 CLI 患者（24 例男性；平均年龄 71.9 ± 10.6 岁）因足部挽救而接受治疗，其顺行再通治疗失败，且经皮逆行至足背或足底动脉的入路不可用。需要高级逆行入路技术来再通靶血管，以恢复缺血组织的血流。在局部给予维拉帕米以控制痉挛后，优先用 21-G 针经第一跖骨背侧动脉入路。当第一跖骨动脉闭塞且不能透视时，直接穿刺足底弓。穿刺后，插入 0.018 或 0.014 英寸导丝和微鞘，以便用球囊对靶血管进行逆行再通，球囊尺寸与靶血管匹配。
25 例逆行经跖骨动脉入路，3 例直接移植弓入路。24 例（86%）技术成功（能够将球囊穿过病变并在标称压力下充气），残余狭窄<50%，无并发症。4 例技术失败是由于经跖骨（n=3）和移植弓入路成功后痉挛或无法真正再进入真腔所致。在平均 5 个月的随访期间（1-8 个月），技术上成功的胫后和足部动脉再通的患者获得了临床改善；经皮压力从 12.5 ± 6.7mmHg 提高至 49.8 ± 9.5mmHg。没有主要截肢，仅有 8 例次要截肢。Kaplan-Meier 分析估计 6 个月时的无截肢生存率为 71%。在高级逆行入路失败的患者中，临床状况没有改善。
作为一种失败的顺行入路患者的挽救策略，逆行高级入路技术似乎是可行和有益的，这些患者不适合逆行足背/足底入路。
Zotero 插件