title: Retrograde transpopliteal access is safe and effective-it should be added to the vascular surgeon's portfolio.
abstract: BACKGROUND
  The aim of the study was to review the outcomes of superficial femoral artery (SFA) interventions using a retrograde transpopliteal access approach after failed antegrade recanalization.
  
  
  METHODS
  A database of patients undergoing endovascular treatment of the SFA between 2008 and 2011 was retrospectively queried, and those cases with transpopliteal artery retrograde access were analyzed. Time-dependent outcomes were determined by Kaplan-Meier survival analyses.
  
  
  RESULTS
  A total of 16 patients (75% men; mean age 61 ± 9 years) underwent retrograde popliteal access after failed antegrade attempts. Patients had multiple cardiovascular comorbidities with a mean modified cardiac index score of 3.1 ± 1.8. The reason for intervention was lifestyle-limiting claudication in 67% of cases and critical ischemia in the remainder. Most of the lesions were Trans-Atlantic Inter-Society Consensus II C and D. Retrograde ultrasound-guided puncture of the popliteal artery was successful in all cases and there were no local site complications. Intervention was successful in 94% of cases. One uncomplicated perforation (7%) was encountered during attempted recanalization of the SFA in the thigh. There was no perioperative morbidity or 30-day mortality. The 30-day major adverse cardiovascular events rate was 6% but both 30-day major adverse limb events and the 30-day major amputation rate were 0%. There was a 40% increase in actual ankle-brachial index (ABI); 93% of patients achieved an ABI rise >0.15. On longer term follow-up, 2 patients developed restenosis and 1 an asymptomatic occlusion. Both restenosis patients required re-angioplasty. Two patients required expected toe amputations as a result of their presenting symptoms. The primary patency was 66 ± 9%, assisted patency 81 ± 9%, and secondary patency 87 ± 8% at 2 years. Limb salvage was 100%. Clinical efficacy was 63 ± 9% at 2 years.
  
  
  CONCLUSIONS
  Ultrasound-guided retrograde transpopliteal access is a safe and successful technique, which extends the ability to perform endovascular interventions after failed antegrade approaches.
authors.affiliation: Division of Vascular and Endovascular Surgery, Department of Cardiovascular Surgery, Houston Methodist Hospital, Houston, TX.
authors.forename: Houssam K
authors.initials: HK
authors.lastname: Younes
authors.affiliation: Division of Vascular and Endovascular Surgery, Department of Cardiovascular Surgery, Houston Methodist Hospital, Houston, TX.
authors.forename: Hosam F
authors.initials: HF
authors.lastname: El-Sayed
authors.affiliation: Division of Vascular and Endovascular Surgery, Department of Cardiovascular Surgery, Houston Methodist Hospital, Houston, TX. Electronic address: mdavies@tmhs.org.
authors.forename: Mark G
authors.initials: MG
authors.lastname: Davies
mesh_terms: D000368:Aged; D000671:Amputation, Surgical; D055109:Ankle Brachial Index; D015897:Comorbidity; D016638:Critical Illness; D016208:Databases, Factual; D018450:Disease Progression; D018572:Disease-Free Survival; D057510:Endovascular Procedures / Q000009:adverse effects / Q000379:methods*; D005260:Female; D006801:Humans; D007383:Intermittent Claudication / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D007511:Ischemia / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D053208:Kaplan-Meier Estimate; D023821:Limb Salvage; D035002:Lower Extremity / Q000098:blood supply*; D008297:Male; D008875:Middle Aged; D058729:Peripheral Arterial Disease / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D011150:Popliteal Artery / Q000000981:diagnostic imaging / Q000503:physiopathology; D012008:Recurrence; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D018084:Ultrasonography, Interventional; D014654:Vascular Patency