“A technique that was popular in the past to treat chronic total occlusions of infrapopliteal arteries has been shown to still be a valuable technique in case of failure to recanalize the occlusion from antegrade,” Andrej Schmidt, MD of the Park hospital and Heart Center (Leipzig, Germany) told attendees at the 37th annual VEITHsymposium™ held at the Hilton Hotel (New York, NY).

Dr. Schmitdt went on to explain that access can be attempted to the anterior tibial artery or dorsalis pedis artery at any level, to the posterior tibial artery at the level of the malleolus and even to the peroneal artery at the distal third by penetrating the membrana interossea with a 7 cm 21 Gauge needle.

In case of a small or distal access artery a “sheathless approach” is performed by inserting a guidewire through the needle and inserting of a support-catheter or OTW-balloon over this wire directly through the skin. If a relatively large artery is punctured, usually the proximal anterior tibial artery, a 4F sheath can be inserted.

After passage of the occlusion from revascularization, the wire is snared from antegrade by manoeuvring the tip of the retrograde guidewire into an angled catheter coming from antegrade down, positioned proximal to the occlusion. Once the guidewire is pulled out of the proximal sheath, the balloon or support-catheter inserted into the foot-artery can be removed and reinserted from antegrade over the guidewire, which is now flossing once through the limb. Having pushed the balloon from antegrade through the CTO the guidewire can be removed from the pedal access and reinserted through the balloon from antegrade, now with the floppy tip directing downwards. While the balloon is inflated in the target lesion a second interventionalist is compressing the pedal puncture site for hemostasis.

In 101 cases of failed antegrade recanalization the retrograde attempt was successful in 95% of these cases. Follow-up angiography was performed in 69 cases to rule out an induction of a stenosis or occlusion of the artery at the access-site during follow-up. One occlusion (1.4%) of the access-artery was found after a mean FU time of 8.4 months. Limb-salvage rate after a FU of maximally 1100 days was 92%.

Dr. Schmidt concluded that the retrograde approach for popliteal to tibial occlusions, where an antegrade recanalization-attempt failed, is a valuable, highly successful and safe interventional option.

Source:

VEITHsymposium