Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa; Department of Vascular Surgery, Faculty of Medicine, Assiut University, Assiut, Egypt.
Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa.
J Vasc Surg. 2018 Oct;68(4):1088-1095. doi: 10.1016/j.jvs.2018.01.028. Epub 2018 Mar 31.
Retrograde infrageniculate access is an alternative treatment strategy for patients who have failed to respond to antegrade endovascular intervention. This study compares the outcomes of infrageniculate retrograde arterial access with the conventional transfemoral access for the endovascular management of chronic lower extremity ischemia.
This was a retrospective single-center review of retrograde endovascular intervention (REI) from 2012 to 2016. Indications for intervention, comorbidities, complications, procedural success, limb outcomes, and mortality were analyzed. Technical failure was defined as the inability to complete the procedure because of failed access or unsuccessful recanalization. Infrageniculate access and transfemoral access were obtained with ultrasound or angiographic roadmap guidance. Patency rates were calculated for technically successful interventions.
There were 47 patients (85% presenting with critical limb ischemia) who underwent sheathless REI after failed antegrade recanalization of TransAtlantic Inter-Society Consensus class D infrainguinal lesions, whereas 93 patients (83% with critical limb ischemia) underwent standard transfemoral access. There were 16 (34%) femoropopliteal, 14 (30%) tibial, and 17 (36%) multilevel interventions in the retrograde group compared with 41 (41%) femoropopliteal, 20 (20%) tibial, and 39 (39%) multilevel interventions in the transfemoral group. Access sites for the retrograde group included the dorsalis pedis (26%), midcalf peroneal (24%), anterior tibial (22%), posterior tibial (26%), and popliteal (2%) arteries. Overall technical success was achieved in 57% of the retrograde group compared with 78% of the transfemoral group. Mean follow-up was 20 months (range, 1-45 months). There were no significant differences in the primary patency rates between the two groups at 1 year and 2 years. The primary assisted patency rates were significantly better in the transfemoral group at 1 year (66% vs 46%; P = .031) and 2 years (56% vs 29%; P = .031). The secondary patency rates were higher in the transfemoral group at 1 year (93% vs 83%; P = .079) and 2 years (91% vs 76%; P = .079), although this did not reach statistical significance. The rate of reintervention was 41% for the retrograde group vs 40% for the transfemoral group. Most of the reinterventions (70% in the retrograde group and 61% in the transfemoral group) were endovascular interventions for a restenosis or occlusion.
Infrageniculate access for REI can result in primary patency rates similar to those of antegrade interventions and does not compromise the access site. Technical failure is high in this initial experience and is mostly due to failed recanalization. Limb salvage may be achieved after technical failure with either repeated antegrade intervention or surgical bypass.
逆行关节下动脉入路是一种治疗经顺行腔内介入治疗失败的患者的替代治疗策略。本研究比较了逆行关节下动脉入路与传统经股动脉入路在治疗慢性下肢缺血中的效果。
这是一项回顾性的单中心研究，研究对象为 2012 年至 2016 年期间接受逆行腔内介入治疗（REI）的患者。分析了介入的适应证、合并症、并发症、手术成功率、肢体结果和死亡率。技术失败定义为由于入路失败或再通不成功而无法完成手术。逆行入路和经股动脉入路均采用超声或血管造影图引导。计算技术成功介入的通畅率。
47 例（85%为严重肢体缺血患者）在经顺行腔内治疗 TransAtlantic Inter-Society Consensus 分级 D 级下肢动脉病变失败后接受了无鞘逆行 REI，而 93 例（83%为严重肢体缺血患者）接受了标准经股动脉入路。逆行组中有 16 例（34%）为股腘动脉病变，14 例（30%）为胫动脉病变，17 例（36%）为多节段病变，而经股动脉组中有 41 例（41%）为股腘动脉病变，20 例（20%）为胫动脉病变，39 例（39%）为多节段病变。逆行组的入路部位包括足背动脉（26%）、小腿中腓动脉（24%）、胫骨前动脉（22%）、胫骨后动脉（26%）和腘动脉（2%）。逆行组的总体技术成功率为 57%，经股动脉组为 78%。两组的 1 年和 2 年的主要通畅率无显著差异。1 年（66%比 46%；P=.031）和 2 年（56%比 29%；P=.031）时，经股动脉组的主要辅助通畅率明显更好。1 年（93%比 83%；P=.079）和 2 年（91%比 76%；P=.079）时，经股动脉组的次要通畅率较高，但这并未达到统计学意义。逆行组的再介入率为 41%，经股动脉组为 40%。逆行组中大多数（70%）和经股动脉组中大多数（61%）的再介入是针对再狭窄或闭塞的腔内介入治疗。
逆行关节下动脉入路用于 REI 可获得与顺行介入治疗相似的主要通畅率，且不会损害入路部位。在这一初步经验中，技术失败率较高，主要是由于再通失败所致。技术失败后，通过再次顺行介入治疗或手术旁路，仍可实现肢体挽救。
