title: Transpedal access after failed anterograde recanalization of complex below-the-knee and femoropoliteal occlusions in critical limb ischemia.
abstract: BACKGROUND
  Successful angioplasty is one of the main factor of limb salvage during critical limb ischemia. In complex femoropopliteal to infrapopliteal occlusions, an anterograde recanalization attempt can fail in up to 20% of the cases. The purpose of this dual center pilot study was to evaluate the acute success and clinical impact of retrograde transpedal access for retrograde below-the-knee and femoropopliteal chronic total occlusions after failed anterograde attempt and to access the late complications at the puncture site.
  
  
  METHODS
  The clinical and angiographic data of 51 consecutive patients with CLI treated by retrograde transpedal recanalization between 2010 and 2011 were evaluated in a pilot study. We have examined the 2-month and 1 year major adverse events (MAEs) and clinical success. In all cases after failure of the anterograde recanalization of occluded below-the-knee segments due to unsuccessful penetration or failed re-entry, the anterior tibial or posterior tibial artery was punctured under fluoroscopic guidance and retrograde recanalization was performed. Direct revascularization was tried firstly following the angiographic zones, but in failed cases indirect revascularization was carried out with increasing the collateral flow to the wound.
  
  
  RESULTS
  Successful direct retrograde revascularization was achieved successfully in 40 patients (78.4%) and indirect revascularization was done in 10 patients (19.6%). Revascularization was failed in one patient (2%). MAE at 2 and 12 months follow-up was 6 (11.7%) and 11 (24%). Limb salvage at 2 and 12 months was 93% and 82.3%, respectively. Balloon angioplasty was performed in all interventions and provisional stenting was done in 34 patients (66.7%). One major and three minor vascular complications occurred after the procedure. The mean basal and control creatinine level was 120.9 ± 133.4 and 123.8 ± 131.3 μmol/L (P = 0.83) after the procedure.
  
  
  CONCLUSIONS
  Failed antegrade attempts to recanalize CTO-s of femoropopliteal and infrapopliteal vessels can be salvaged using a retrograde transpedal access, with a low acute and late complication rate. This technique could be valuable for patients with critical limb ischemia due to femoropopliteal and infrapopliteal occlusions.
authors.affiliation: Semmelweis University, Cardiac and Vascular Center, Budapest, Hungary; Bács-Kiskun County Hospital, Teaching Hospital of the University of Szeged, Invasive Cardiology Department, Kecskemét, Hungary.
authors.forename: Zoltán
authors.initials: Z
authors.lastname: Ruzsa
authors.forename: Balázs
authors.initials: B
authors.lastname: Nemes
authors.forename: Zoltán
authors.initials: Z
authors.lastname: Bánsághi
authors.forename: Károly
authors.initials: K
authors.lastname: Tóth
authors.forename: Ferenc
authors.initials: F
authors.lastname: Kuti
authors.forename: Slavka
authors.initials: S
authors.lastname: Kudrnova
authors.forename: Balázs
authors.initials: B
authors.lastname: Berta
authors.forename: Kálmán
authors.initials: K
authors.lastname: Hüttl
authors.forename: Béla
authors.initials: B
authors.lastname: Merkely
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000800:Angioplasty, Balloon / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods*; D003251:Constriction, Pathologic; D016638:Critical Illness; D005260:Female; D005263:Femoral Artery / Q000000981:diagnostic imaging / Q000503:physiopathology; D006801:Humans; D007511:Ischemia / Q000175:diagnosis / Q000503:physiopathology / Q000628:therapy*; D023821:Limb Salvage; D008297:Male; D008875:Middle Aged; D018579:Patient Selection; D058729:Peripheral Arterial Disease / Q000175:diagnosis / Q000503:physiopathology / Q000628:therapy*; D010865:Pilot Projects; D011150:Popliteal Artery / Q000000981:diagnostic imaging / Q000503:physiopathology; D011446:Prospective Studies; D011677:Punctures; D011859:Radiography; D019233:Retreatment; D012307:Risk Factors; D015607:Stents; D017211:Treatment Failure
keywords: critical limb ischemia; retrograde recanalization; transpedal access